Transient Ischemic Attack Research Articles

The Management of Symptomatic Moyamoya Disease in Pediatric Patients: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES: The optimal management strategy for pediatric patients with symptomatic moyamoya disease (MMD) is not well established. This systematic review and meta-analysis compares surgical vs conservative management and direct/combined bypass (DB/CB) vs indirect bypass (IB) for pediatric patients with symptomatic MMD. METHODS: MEDLINE and PubMed were searched from inception to March 17, 2024. For analysis of surgical vs conservative treatment, the primary and secondary outcomes were follow-up ischemic stroke and intracranial hemorrhagic events, respectively. For analysis of DB/CB vs IB, the primary outcome was follow-up ischemic stroke, and secondary outcomes included follow-up transient ischemic attack, new or worsened seizures, symptomatic improvement, modified Rankin Scale score ≤2, and Matsushima grade A at the last follow-up. RESULTS: Twenty-two included studies yielded 1091 patients, with a median follow-up duration of 35.7 months. Regarding surgical vs conservative management, 428 patients were analyzed. Surgical treatment was associated with lower odds of ischemic stroke (odds ratios [OR] = 0.33 [95% CI, 0.11-0.97], P = .04), and intracranial hemorrhagic events tended to be lower with surgery (OR = 0.25 [0.06-1.03], P = .05). Regarding DB/CB techniques vs IB, 875 patients were analyzed. The groups had similar rates of ischemic stroke (OR = 0.79 [0.31-1.97], P = .61), transient ischemic attack (OR = 1.27[0.46-3.55], P = .64), new or worsened seizures (OR = 1.05[0.3-3.65], P = .93), symptomatic improvement (OR = 2.45[0.71-8.45], P = .16), and follow-up modified Rankin Scale ≤2 (OR = 1.21 [0.16-8.85], P = .85). CB was associated with higher Matsushima grade A relative to IB (OR = 3.44 [1.32-9.97], P = .01). CONCLUSION: Surgical revascularization yielded more favorable clinical outcomes than conservative management in this meta-analysis. Clinical outcomes were similar between DB/CB vs IB techniques. Surgical flow augmentation, either by DB/CB or IB, seems to benefit pediatric patients with symptomatic MMD.

Novel Multicomponent Digital Care Assistant and Support Program for People After Stroke or Transient Ischaemic Attack: A Pilot Feasibility Study

Evidence is increasing for digital health programs targeting the secondary prevention of stroke. We aimed to determine the feasibility of the novel Care Assistant and support Program for people after Stroke (CAPS) or transient ischaemic attack (TIA) by combining person-centred goal setting and risk-factor monitoring through a web-based clinician portal, SMS messages, a mobile application (app), and a wearable device. We conducted a 12-week mixed-methods, open-label feasibility study. Participants (6 months–3 years after stroke or TIA, access to the internet via a smartphone/tablet) were recruited via the Australian Stroke Clinical Registry. Participants set one or two secondary prevention goals with a researcher and provided access and training in technology use. Feasibility outcomes included recruitment, retention, usability, acceptability, and satisfaction. Secondary outcomes included goal attainment, health outcomes, and program costs. Following 600 invitations, 58 responded, 34/36 (94%) eligible participants commenced the program (one withdrawal; 97% retention), and 10 were interviewed. Participants (27% female, 33% TIA) generally rated the usability of the mobile application as ‘Good’ to ‘Excellent’ (System Usability Scale). Most (94%) agreed the program helped with engagement in health self-monitoring. Overall, 52 goals were set, predominantly regarding exercise (21/52), which were the most frequently achieved (9/21). At 12 weeks, participants reported significant improvements (p < 0.05) in self-efficacy (Cohen’s d = 0.40), cardiovascular health (d = 0.71), and the mental health domain of the PROMIS GH (d = 0.63). CAPS was acceptable, with good retention and engagement of participants. Evaluation of this program in a randomised controlled trial is warranted.

Transient Ischemic Attack and Mild Stroke Participant Perspectives on Barriers and Enablers to Participation in Cardiovascular Rehabilitation

Background Exercise-based cardiac rehabilitation reduces the risk factors and recurrence of cardiovascular disease in patients with coronary heart disease. Despite similar risk factors, people with transient ischemic attack (TIA) and mild stroke do not attend cardiac rehabilitation. Cardiovascular rehabilitation (CVR), including TIA, stroke, and coronary heart disease, could be a solution for increasing participation. Perspectives from TIA and stroke survivors on barriers and enablers to participation in CVR are limited, and implementation strategies for CVR are currently unknown. Objectives We sought to determine (1) What were the perspectives of participants with TIA and mild stroke on barriers and enablers to uptake, engagement, and participation in CVR? and (2) What implementation strategies may influence people with TIA and mild stroke to participate in CVR? Methods In-depth semistructured interviews were conducted with CVR participants. Inductive thematic analysis was completed before deductively mapping themes to implementation frameworks, the Capability, Opportunity, Motivation, and Behavior Model and Theoretical Domains Framework. Results Twenty participants aged 73 ± 11 years were interviewed. Most were men, stroke survivors, tertiary educated, and retired. Six themes were generated to explain the barriers and enablers to CVR participation. Themes and subthemes mapped to 8 Theoretical Domains Framework domains and 5 Capability, Opportunity, Motivation, and Behavior constructs. Prioritizing participants' physical and social opportunities, reflective motivation, and physical and psychological capabilities may improve their participation in CVR. Conclusions Barriers and enablers to CVR participation were similar to those in the coronary heart disease population. Increasing access and availability of CVR for people with TIA and mild stroke should be prioritized for future implementation.

Abstract 4121589: Sex differences in Social Determinants of Health and Adverse Outcomes in Atrial Fibrillation: A UK Biobank Study

Background: Beyond the risk of thromboembolic stroke, people with atrial fibrillation (AF) are substantially burdened with a higher incidence of cardiovascular mortality, even among patients treated with anticoagulants. The reasons behind these outcomes are only partially understood. Social determinants of health (SDOH), strong independent predictors of major adverse cardiovascular events (MACE) in several cardiac diseases, may play a role; however, their impact on AF prognosis and the differences in SDOH by sex have been insufficiently explored. Objective: We investigated the sex differences in the association between SDOH and MACE in patients with AF. Methods: Data from the UK Biobank included participants enrolled from 2006 to 2010. An incident AF patient cohort, free of stroke and MI was created. Seventeen SDOH derived from three domains:: socio-economic status, psychosocial factors, and neighborhood/living environment were identified Cox proportional hazards models were used to evaluate the associations of individual SDOH components with the risk of MACE stratified by sex. Covariates including all variables of the CHA 2 DS 2 -VASc Score (Congestive heart failure, Hypertension, Age, Diabetes, prior stroke or transient ischemic attack, Vascular disease and Sex), current use of antiplatelet therapy or anticoagulation, smoking and body mass index. The primary outcome was a composite of MACE (including stroke, transient ischemic attack and arterial thromboembolic event, MI and cardiovascular mortality) and all-cause mortality. Results: A total of 23,113 participants with AF (mean age, 62.44 ± 5.88 years; female sex 39.7%) were included. The composite outcome occurred in 5,151 (22%) of participants over 10-year follow up. In the multivariate adjusted model, several SDOH were independently associated with an increased risk of adverse outcomes. Males showed a broader range of SDOH that were significantly associated with outcomes, including unfavourable economic factors and low social support. Despite females had fewer significant SDOH, education-related factors and local crime rates were significant predictors of adverse outcomes (Figure 1). Conclusions: Adverse SDOHs are associated with a higher risk of MACE and all-cause mortality in AF, with sex-specific variations. These findings underscore the need of incorporating routinely SDOH assessment into clinical practice to more accurately stratify risk and tailor preventive strategies based on sex-specific data.

Abstract 4135286: Comparative Efficacy of Intracardiac and Transesophageal Echocardiography in Left Atrial Appendage Occlusion: A Meta-Analysis of Clinical Outcomes

Background: Left atrial appendage occlusion (LAAO) is essential for stroke prevention in patients with non-valvular atrial fibrillation where anticoagulation is contraindicated. Intracardiac Echocardiography (ICE) has been proven effective and safe for LAAO since 2011, yet adoption rates remain low, with only 2.2% of LAAOs guided by ICE between 2015 and 2019. Transesophageal Echocardiography (TEE), the current gold standard, and ICE differ significantly in operational dynamics and patient impacts, influencing procedural outcomes. Objective: This study aims to compare the efficacy and safety of ICE and TEE in facilitating LAAO, offering insights into their comparative clinical use. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. Searches were performed in MEDLINE/PubMed, OVID, and Scopus through December 2023, comparing ICE and TEE in LAAO. Inclusion criteria centered on studies reporting technical success, with secondary outcomes including length of stay (LOS), mortality, and adverse outcomes such as stroke, transient ischemic attacks (TIA), pericardial effusion, cardiac tamponade, device thrombosis, device embolization, and peri-device leaks. Data synthesis employed statistical methods utilizing R Studio. Results: Fourteen studies involving 4184 patients were included. The meta-analysis revealed no significant differences in technical success (OR 1.34, 95% CI: [0.76, 2.36]), LOS (OR 1.66, 95% CI: [0.80, 3.42]), or mortality (OR = 1.00, 95% CI: [0.50, 2.00]) between ICE and TEE. Similarly, non-significant differences were noted in stroke, TIA, pericardial effusion, and device leaks, with minimal heterogeneity (I 2 = 0%). Conclusion: ICE and TEE provide comparable clinical outcomes in LAAO, with no significant efficacy or safety differences. These results suggest that the choice between ICE and TEE should be based on procedural convenience, patient anatomy, and resource availability, rather than clinical outcomes alone. The equivalence in performance between these modalities allows for flexibility in clinical practice, ensuring that patient care can be customized to individual needs without compromising safety or effectiveness.

Abstract 4138277: Protamine Administration and Bleeding Risk Following Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Background: Bleeding risk is a major concern for patients receiving transcatheter aortic valve implantation (TAVI) due to heparin use. In recent studies, Heparin antagonists, such as protamine, have shown potential in mitigating this complication. We aim to evaluate its potential role in reducing the risk of bleeding in patients post-TAVI. Methods On March 18, 2024, related articles were searched in the following databases: PubMed, Embase, Scopus, Web of Science, Cochrane Library, Wiley Library, VHL, Google Scholar, and clinicaltrials.gov. The inclusion criteria consisted of studies that reported the use of protamine in patients who underwent TAVI, with the aim of reducing bleeding risk compared to administering a placebo or no treatment. Our primary outcomes included major bleeding, life-threatening bleeding, the need for blood transfusion, the 30-day mortality rate, and any events of stroke or transient ischemic attack (TIA). The effect size was calculated using the odds ratio with a 95% confidence interval. Meta-analysis was conducted based on random-effect model using Revman. Results Out of the 14,705 articles we obtained, only 5 papers were included. One was a randomized controlled trial; the remaining 4 were observational cohorts with control groups. These studies comprised a total of 3,502 patients. Protamine significantly reduced major bleeding (OR 0.44, 95% CI 0.29-0.69, p = 0.0003, I 2 = 37%), especially with full-dose administration (1 mg/100 U UFH) compared to partial-dose administration (0.5 mg/100 U UFH) (OR 0.38, 95% CI 0.25-0.58, p < 0.00001, I 2 = 0%). Similarly, protamine significantly reduced life-threatening bleeding (OR 0.37, 95% CI 0.20-0.67, p = 0.001, I 2 = 4%), particularly with full-dose usage compared to partial-dose (OR 0.37, 95% CI 0.18-0.73, p = 0.004, I 2 = 0%). However, no significant difference was observed in the need for blood transfusion (OR 0.75, 95% CI 0.46-1.24, p = 0.27, I 2 = 33%), stroke/TIA risk (OR 0.82, 95% CI 0.41-1.61, p = 0.56, I 2 = 49%), or 30-day mortality (OR 0.93, 95% CI 0.62-1.39, p = 0.73, I 2 = 0%). Conclusions The use of protamine appears to significantly reduce major and life-threatening bleeding. The need for blood transfusion, risk of stroke or TIA, and 30-day mortality did not show significant differences. These findings suggest that protamine may be an effective intervention for reducing bleeding complications post-TAVI. However, large randomized controlled trials are needed to validate these findings.

Abstract 4138757: Lipid-Lowering Therapy Intensification and Low-Density Lipoprotein Cholesterol Testing Following a Major Cardiovascular Event or Procedure in Adult Patients in the United States

Background: Optimizing lipid-lowering therapy (LLT) use is foundational to reduce atherosclerotic cardiovascular disease (ASCVD) risk, especially among patients who have already experienced an ASCVD event. This study aimed to evaluate the patterns of LLT intensification and LDL-C testing within 12 months following an ASCVD event in US patients. Methods: Adults who experienced an ASCVD event (acute coronary syndrome, coronary revascularization, stable angina, ischemic stroke, transient ischemic attack, or peripheral arterial disease) between January 1, 2016 and December 31, 2022 in the IQVIA Longitudinal Access and Adjudication Data were included. The first instance of LLT intensification after the event was defined as an increase from a low-moderate to high intensity statin, or the initiation of statins, ezetimibe, PCSK9i, or bempedoic acid in addition to a baseline LLT regimen that did not include these medications. Baseline medication use was defined during 6 months before the ASCVD event. Results: Among 6,028,573 patients who had an eligible ASCVD event (mean age: 63.6 years, 51.5% male), 53.9% were not taking any LLT and 43.2% were taking statins only (low-moderate intensity: 26.7%; high intensity: 16.4%) during baseline. Within 1, 3, and 12 months after the event, 16.3%, 21.3%, and 30.0% of patients intensified LLT, respectively. Among patients who intensified LLT within 12 months (n= 1,820,246), the most commonly observed intensification was from no LLT use at baseline to low-moderate (29.0%) or high-intensity statins (43.5%), followed by intensification from low-moderate to high-intensity statins (20.3%). LDL-C values at baseline were available in a subset of 10.7% of patients, with the median being 95 mg/dL (78.9% ≥70 mg/dL). LDL-C values were observed in 17.7% of patients within 12 months after the ASCVD event, with the median being 84 mg/dL (68.3% ≥70 mg/dL). Conclusions: Within 12 months after an ASCVD event, only about one-third of patients intensified LLT and two-thirds did not achieve guideline-recommended LDL-C levels. The results highlight a missed opportunity to reduce recurrent ASCVD events. Future effort is warranted to address the clinical inertia that may be contributing to this unmet need.

Abstract 4123899: Stroke Risk in Patients with an Isolated Interventricular Membranous Septal Aneurysm

Aim: This study investigates the prevalence of isolated interventricular membranous septal (IVMS) aneurysms detected via echocardiography and assesses the associated stroke risk without other classical risk factors. Methods: We searched the echocardiography database at Mount Sinai Morningside from January 2017 to September 2023. Identified echocardiograms were reviewed to confirm IVMS aneurysms and exclude sinus of Valsalva aneurysms. Patients with concurrent structural heart anomalies were excluded. Medical records were examined for baseline characteristics, risk factors, and cortical brain infarcts. Results: From 51,732 subjects, 18 were identified with IVMS aneurysms, yielding a prevalence of 0.04%. Four patients with significant structural heart disease were excluded, resulting in a final sample size of 14. Of these, 9 (64%) were female with a mean age of 59.6, and 5 (36%) were male with a mean age of 55.4. The mean BMI was 27.9 kg/m 2 , with 4 classified as obese. All patients were nonsmokers; 2 had a family history of stroke. One patient had diabetes, 8 had hyperlipidemia, and 9 had hypertension. Only one patient had paroxysmal atrial fibrillation, with a CHA2DS2-VASc score of 0. Echocardiography revealed structurally normal hearts with a mean left ventricular ejection fraction of 61% and a mean left atrial volume index of 24.8 mL/m 2 . The mean neck diameter of the aneurysm was 8.7 mm, and the mean diameter was 11.9 mm. Two patients had inter-atrial septal aneurysms, and one had a patent foramen ovale. Out of the 14 patients, 5 had a history of ischemic stroke (4) or transient ischemic attacks (1), all of whom were 64 years or younger with a mean RoPE Score of 6 and a mean CHA2DS2-VASc score of 1.6 at the time of their first neurologic event. All patients were treated with aspirin and statin therapy. Two patients had recurrent strokes, one of whom had four recurrent strokes, all cortical infarcts. These patients were switched to clopidogrel after 3 months of dual antiplatelet therapy. No anticoagulation was used. Conclusion: This retrospective study highlights a notable association between isolated IVMS aneurysms and an increased risk of ischemic stroke (36%) and recurrent ischemic stroke (14%). Despite their rarity, these anomalies should be considered in unexplained strokes. Optimal management strategies remain ambiguous, but anticoagulation may be favored based on presumed stroke mechanisms. Large-scale multicenter studies are needed for validation.

Abstract 4138330: Clinical outcomes in rheumatic mitral stenosis and the novel Yeo’s index

Introduction: Yeo’s index, the product of the mitral leaflet separation index and dimensionless index of mitral valve, was recently described to accurately identify severe rheumatic mitral stenosis (MS). We aimed to study the association between Yeo’s index and clinical outcomes in patients with rheumatic MS. Methods: We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo’s index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, mitral valve intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. Results: After a median follow up of 6.3 years, 145 patients (48.8%) developed the composite outcome. Yeo’s index ( p <0.001), mitral valve area (MVA) by pressure half-time (PHT) ( p= 0.028) and planimetry ( p <0.001), age ( p =0.016), history of diabetes mellitus ( p =0.029), previous HF ( p =0.021), left ventricular ejection fraction ( p =0.022), and pulmonary artery systolic pressure ( p =0.007) were univariately associated with the composite outcome. Yeo’s index remained independently associated ( p <0.001, HR 0.094, 95% CI 0.260-0.340) with the composite outcome in multivariate analysis. In subgroup analysis of patients without pre-existing AF, Yeo’s index was independently associated ( p =0.024, HR 0.354, 95% CI 0.143-0.874) with new onset AF. MVA by PHT and planimetry were not associated with new onset AF. Conclusion: Yeo’s index was independently associated with clinical outcomes in patients with rheumatic MS.

Abstract 4139177: Five-Year Clinical Outcomes of Balloon-Expandable versus Self-Expanding Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annulus

Introduction: Self-expanding transcatheter aortic valves (SEV) have reportedly better hemodynamic outcomes, and similar clinical outcomes compared to balloon-expanding valves (BEV) at 1 year in patients with a small aortic annulus based on results from the SMART trial. Head-to-head comparison of long-term clinical outcomes, however, is lacking. Objectives: To compare the long-term (5 years) echocardiographic and cardiovascular outcomes in BEV versus SEV in patients with small aortic annulus undergoing transcatheter aortic valve replacement (TAVR). Methodology: The RESOLVE registry included consecutive patients who underwent TAVR and survived up to 30 days at Cedars-Sinai Medical Center with either BEV or SEV from 2015 to 2020, with clinical variables obtained from the STS/TVT registry. CT core lab analysis identified patients with a small aortic annulus (<430 mm 2 ), who were systematically followed up with clinical exams and echocardiography until December 2023. The primary outcome was a composite of all-cause mortality, stroke or transient ischemic attack, or heart failure hospitalization at 5 years. Results: Out of 1392 patients, a total of 423 met criteria for small aortic annulus (345 BEV, 78 SEV), with a median follow-up of 5 years (4-6 years). There were no significant differences in baseline sociodemographic and clinical characteristics between the BEV and SEV groups. (Figure 1) The post-TAVR invasive aortic valve mean gradient were similar in both groups [Median (IQR): BEV:3(1-5.8), SEV: 3.4(0.4-6.6), p 0.58], while echocardiographic gradients were higher in BEV group [Median (IQR): BEV:12 (9-15), SEV:8(6-11), p<0.001)].There was no significant difference in primary outcome at 5 years in Cox multivariable regression analysis (HR:1.21, 95% CI 0.81-1.82, p 0.33) (Figure 2). There were no significant differences in other clinical endpoints at 5 years, although patients with SEV had lower echocardiographic gradients and higher indexed effective orifice area. (Figure 2-3) Conclusion: Post-TAVR invasive aortic valve gradients were similar between BEV and SEV, despite higher echocardiographic transaortic gradients in BEV patients. We found no significant difference in 5-year clinical outcomes between patients who received TAVR with BEV or SEV.

Abstract 4120716: Aspirin plus clopidogrel versus aspirin alone in patients with mild-to-moderate stroke: A systematic review and meta-analysis

Background: Studies have shown that dual antiplatelet therapy (DAPT) is superior to aspirin monotherapy in patients with minor stroke or transient ischemic attacks. However, there is limited evidence regarding the efficacy and safety of DAPT in mild-to-moderate stroke. Aims: We conducted a systematic review and meta-analysis to evaluate whether DAPT is superior to single antiplatelet among patients with mild to moderate ischemic stroke. Methods: PubMed/MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov were searched from inception till March 2024 for published randomized controlled trials (RCTs) and observational studies that compared aspirin plus clopidogrel versus aspirin monotherapy in patients with mild-to-moderate stroke. R version 4.3.2 was used to calculate risk ratios (RRs) with 95% confidence intervals (95% CIs). Results: A total of 4 studies reporting data for 15,173 patients were included. DAPT was associated with a reduced risk of early neurological deterioration (END) (RR: 0.55, 95% CI: 0.28 to 1.05, p = 0.07 Figure 1A) and recurrent ischemic stroke (RR: 0.65, 95% CI: 0.41 to 1.04, p = 0.07 Figure 1B) without reaching statistical significance. The risk of recurrent hemorrhagic stroke (RR: 0.94, 95% CI: 0.47 to 1.86, p = 0.86 Figure 2A), all-cause death (RR: 0.75, 95% CI: 0.52 to 1.08 Figure 2B), or myocardial infarction (RR: 0.83, 95% CI: 0.45 to 1.54 Figure 2C) was comparable across the two groups. DAPT was not associated with an increased risk of any bleeding event (RR: 0.70, 95% CI: 0.36 to 1.36 Figure 2D). Conclusion: DAPT possibly reduces the risk of END and recurrent ischemic stroke as compared to aspirin monotherapy in mild or moderate stroke without increasing the risk of bleeding events.

Transcatheter Aortic Valve Replacement in Patients With Geographic and Socioeconomic Vulnerabilities

Background Transcatheter aortic valve replacement (TAVR) is an established treatment for patients with severe aortic stenosis (AS). It remains unclear whether disparities exist in rural or socially vulnerable populations undergoing TAVR. This study assessed whether outcomes differ based on geographic location or vulnerability of patients undergoing TAVR. Methods Patients undergoing TAVR at a single institution from August 2012 to June 2023 were studied (n = 1565). Zip codes determined Social Vulnerability Index (SVI) and measured distance to our facility. Outcomes defined by the Valve Academic Research Consortium 3 (VARC-3) included stroke, transient ischemic attack (TIA)/delirium, pacemaker implantation, new atrial fibrillation/atrial flutter, and myocardial infarction (MI). Average time between preoperative coronary angiogram (CATH)/computed tomography angiography (CTA) and TAVR was calculated. Kaplan-Meier curves estimated survival probability. Results The average time between CATH and TAVR in patients living furthest away was ∼9 days more than patients living closest to the implant site. The average number of days between CATH and TAVR for low and high SVI were 71 and 78 days, respectively. The average number of days between CTA and TAVR for low and high SVI were 40 and 39 days, respectively. Discussion Further distances traveled were associated with longer wait times between preoperative workup and TAVR. Patients with longer waits between CATH and TAVR had no differences in medium-term survival probability but had decreased long-term survival probability compared to patients with rapid pre-procedural evaluation. Although geographic and socioeconomic vulnerability can disadvantage patients, our study demonstrates that patients undergoing TAVR can have timely care and similar outcomes.

The association between precuneus cortex thickness and mild behavioral impairment in patients with mild stroke

The association between precuneus cortex thickness and mild behavioral impairment in patients with mild stroke

The Effectiveness of the Moyamoya Healthy Youth Application for the Salutogenesis of Adolescents With Moyamoya Disease: A Randomized Controlled Trial

ABSTRACTAdolescents with moyamoya disease can experience unexpected transient ischemic attacks, significantly impacting their daily lives. This study aimed to examine the effectiveness of the Moyamoya Healthy Youth application for adolescents with moyamoya disease. The research employed a parallel, two‐group randomized controlled trial with a repeated measures design. A total of 64 adolescents with moyamoya disease were participated. The intervention group applied the application, whereas the wait‐list group received their usual care from an outpatient clinic. The outcome variables were assessed three times during the study, from July 2021 to March 2022. Repeated measures ANOVA and Friedman test were used to analyze results. The intervention group exhibited significant improvements in stress and health behavior. No statistically significant improvement was observed in moyamoya disease knowledge, social support, sense of coherence, depression, cortisol, and symptoms. This mobile‐based strategy empowered adolescents to monitor their health behaviors and cope with stress. This intervention is a promising strategy for health care providers to enhance self‐management skills and achieve better quality of life in such adolescents.Trial Registration: Korea Clinical Trial Registry KCT0006451. https://cris.nih.go.kr/cris/search/detailSearch.do/21925

Diastolic Dysfunction and the Risk of Stroke and Major Bleeding

BACKGROUND: Left ventricular diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident stroke and transient ischemic attack (TIA) and with bleeding events is not known. We performed this observational cohort analysis to examine the impact of DD on the risk of stroke/TIA and major bleeding. METHODS: Patients who underwent at least 1 cardiac echocardiogram and were followed for at least 3 months were included in this study. Patients with a prior history of stroke, TIA, or major bleeding, as determined by International Classifications of Diseases codes, were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups based on the most severe DD assessment. Patients in whom the presence of DD could not be determined were excluded. The final study cohort was followed to the end point of hospital admission for stroke/TIA and major bleeding, and independent predictors of these events were evaluated using the multivariable Cox proportional hazards method. RESULTS: The final study cohort (age, 56±18 years; 56% women) had 96 702 patients with no DD and 18 164, 5881, and 1340 patients with DD grades I, II, and III, respectively. Over a median follow-up of 3.4 years, 2938 (2.4%) patients were hospitalized for stroke/TIA and 5567 (4.6%) for major bleeding. After adjusting for age, the CHA 2 DS 2 -VASc score, chronic kidney disease, use of antiplatelet agents, use of anticoagulation agents, the year of echocardiographic testing, household income, and history of atrial fibrillation, DD remained a strong predictor of incident stroke/TIA (hazard ratio, 1.22 per grade increase in DD [95% CI, 1.16–1.29]; P <0.001) and major bleeding (hazard ratio, 1.20 per grade increase in DD [95% CI, 1.16–1.25]; P <0.001). CONCLUSIONS: DD is independently associated with a higher risk of cerebrovascular accidents and major bleeding. DD should be considered when counseling patients regarding their risk profile and management options.

Assessment of Ischemic Stroke or Transient Ischemic Attack of Undetermined Cause Using Cardiac Magnetic Resonance Imaging

Assessment of Ischemic Stroke or Transient Ischemic Attack of Undetermined Cause Using Cardiac Magnetic Resonance Imaging

Hospitalization costs in patients with stroke in southeastern China: a retrospective population-based cohort study, 2019–2022

IntroductionStroke remains a predominant cause of mortality and accounts for one-third of all stroke-related fatalities worldwide. Increasing expenses associated with stroke are a matter of significant concern; however, this aspect has been insufficiently examined.MethodsThe purpose of this study was to analyze in-hospital stroke costs and explore potential factors influencing them across stroke subtypes. The records of stroke patients from 50 hospitals in southeastern China between 2019 and 2022 were reviewed using multistage stratified cluster random sampling. We focused on the cost patterns of four stroke types and used multivariate linear regression to identify cost determinants.ResultsA total of 417 (1.1%) patients had subarachnoid hemorrhage (SAH), 9309 (25.9%) had intracerebral hemorrhage (ICH), 22,248 (61.8%) had ischemic stroke (IS), and 4025 had transient ischemic attack (TIA). The number of stroke patients has sharply increased since the onset of COVID-19, with a majority of them being male (72.2%). Despite the fact that hospitalization costs are highest in tertiary hospitals (Chinese yuan [CNY] 30610.8/United States dollar [USD] 4551.0, interquartile range [IQR] 9944.9, 29668.4/1478.6, 4410.9), the majority of patients are admitted to tertiary hospitals (74.6%) or public hospitals (90.2%). Across all stroke subtypes, patients with SAH had the highest costs (CNY 93,454.9/USD13894.4, IQR 12273.2, 169920.0/1824.7, 25262.8), followed by those with ICH (CNY 48,724.2/USD 7244.0, IQR 16789.6, 57540.7/2496.2, 8554.8), IS (CNY 26,550.3/USD3947.4, IQR 8684.2, 28697.7/1291.1, 4266.6), and TIA (CNY 11,170.1/USD1660.7, IQR 6823.7, 12965.2/1014.5, 1927.6). Therapy fees comprised a significant portion of costs in ICH and IS cases (47.9% and 42.7%, respectively). Materials accounted for the highest proportion of expenses for SAH (56.1%), whereas patients with TIA spent more time on examinations (34.1%). Linear regression analysis revealed that length of stay (LOS), stroke subtype, hospital level, and stroke type were key factors influencing hospitalization costsDiscussionThe visiting rate and charges were highest in tertiary public hospitals, and hospitalization costs were higher in hemorrhagic types of stroke than in ischemic types of stroke; the proportion of hospitalization cost categories varied among different types of stroke, with LOS, hospital type, and level substantially affecting hospitalization costs. Enhancing medical insurance reimbursement rates for hemorrhagic strokes, implementing a hierarchical medical system, tailoring cost categories to accommodate varying stroke subtypes, and shortening LOS may help alleviate the economic burden of stroke.

Comorbidity problems in patients with osteoporosis

BACKGROUND: Osteoporosis is a metabolic skeletal disease characterized by decreased bone mass, impaired microarchitecture of bone tissue and, as a consequence, fractures with minimal trauma. The social significance of osteoporosis is determined by its consequences — fractures of the vertebral bodies and bones of the peripheral skeleton, leading to high medical costs and causing a high level of disability, including disability and mortality. Osteoporosis is most often combined with cardiovascular diseases caused by atherosclerosis, which are widespread and are the leading cause of disability and mortality. A small number of studies have been devoted to the study of the features of clinical manifestations of cardiovascular diseases in the combination of coronary heart disease and osteoporosis. AIM: To identify the frequency and severity of comorbid diseases and their risk factors in postmenopausal osteoporosis. MATERIALS AND METHODS: A retrospective and prospective cohort study was conducted from 2013 to 2023. 8250 women with postmenopausal osteoporosis were examined and the data from the medical records of these patients who applied to the Osteoporosis Center of the North-Western State Medical University named after I.I. Mechnikov of the Ministry of Health of the Russian Federation from 2013 to 2020 were analyzed. At the prospective stage, two comparison groups of 100 patients with and without postmenopausal osteoporosis were formed from 500 patients with comorbid diseases (coronary heart disease, hypertension, type 2 diabetes, stroke, transient ischemic attack). Bone mineral density was assessed based on the Hologic Discoveri Wi dual-energy X-ray absorptiometry at 2 points in the lumbar spine (L1–L4) and the femoral neck. Along with traditional laboratory examination methods, bone metabolism markers (total calcium, phosphorus, vitamin D, urine analysis for deoxypyridinoline, C-terminal telopeptide of type 1 collagen, osteocalcin, alkaline phosphatase, parathyroid hormone) were assessed dynamically. In all the patients, along with a general clinical examination, an assessment of risk factors for cardiovascular disease and osteoporosis was performed. RESULTS: Body mass index was higher in the group of patients with osteoporosis — 28.4 (26.9–32.4) kg/m2 (p 0.001), versus 27.64 (25.8–30.0) kg/m2 (p 0.05). Bone mineral density in the group of patients with osteoporosis was statistically lower than in the group without osteoporosis. In the group of patients with osteoporosis, the risk of fractures was high and amounted to 37 (95% confidence interval 15.0–38.50) %, p 0.001), versus in the control group 9.55 (95% confidence interval 7.67–15.0) % (p 0.001) according to the FRAX questionnaire for the Russian Federation. In the group of patients with osteoporosis, the Charlson index values were 5.1 (95% confidence interval 4.7–5.6) points. As a result of the correlation analysis, a reliable positive relationship was revealed between low bone mineral density L1–L4 and hip with bone metabolism: alkaline phosphatase, C-terminal telopeptide of type 1 collagen, vitamin D, osteocalcin, urinary deoxypyridinoline. We found a negative relationship between bone mineral density and the Charlson index, absolute ten-year risk of hip fracture and the duration of early menopause, and the level of hypertension. To assess the dependence of QRISK3-2018 on osteoporosis risk factors in the group of patients with osteoporosis, multiple linear regression was performed. This model was characterized by a statistically significant correlation between the factors and the dependent variable of high tightness. The coefficient of determination was 0.608, indicating a 60.8% contribution of the factors taken into account in the model to the variance of QRISK3-2018. CONCLUSIONS: In women with postmenopausal osteoporosis, comorbid pathology is more common, aggravating the course of the disease. Knowledge of the prevalence of concomitant pathology and joint risk factors will make it possible to simultaneously form groups at increased risk of development, which will ensure prevention of both diseases with the same non-medical means and drugs.

Increased risk of major adverse cardiovascular events in patients with deep and infected diabetes-related foot ulcers.

Diabetes-related foot ulceration (DFU) is associated with increased cardiovascular risk, but the mechanisms remain unclear. Inflammation and infection are mediators of CVD, which may be important in DFU. Prospectively collected data from patients attending a multidisciplinary DFU service were analysed. A deep ulcer was defined as one that reached muscle, tendon or deeper structures. Patients were categorised into four DFU groups: not deep and no infection (D-/I-), not deep but infected (D-/I+), deep with no infection (D+/I-) or deep with infection (D+/I+). Incident major adverse cardiovascular events (MACE) were defined as hospitalisation for myocardial infarction, stroke or transient ischaemic attack, or heart failure. Survival analyses were performed using the logrank test and multivariate Cox regression. Of 513 patients, 241 (47.0%) were in the D-/I- group, 110 (21.4%) were in the D-/I+ group, 35 (6.8%) were in the D+/I- group and 127 (24.8%) were in the D+/I+ group. MACE or all-cause mortality occurred in 75 patients (14.6%), and MACE alone occurred in 46 patients (9.0%) after median follow-up of 381 days (IQR 220-551) and 404 days (IQR 228-576), respectively. Infection was associated with significantly higher MACE or all-cause mortality (21.5% vs 8.7%; p<0.001) and MACE alone (13.5% vs 5.1%; p=0.003). MACE or all-cause mortality was significantly higher in the D+/I+ group (D-/I- 7.9%; D-/I+ 15.5%; D+/I- 14.3%; D+/I+ 26.8%; p<0.001), as was MACE alone (D-/I- 5.0%; D-/I+ 10.9%; D+/I- 5.7%; D+/I+ 15.7%; p=0.017). Infection and a deep ulcer were independent predictors of adverse outcomes. Deep and/or infected DFUs are associated with increased cardiovascular risk compared with DFUs that are not deep or infected. These findings provide a potential mechanistic explanation that requires investigation.

Prevalence of frailty in the TIA clinic and its associations with mortality.

Introduction Frailty is a clinical syndrome of increased vulnerability to stressors. Frailty is associated with adverse outcomes after stroke, but frailty and transient ischaemic attack (TIA) are less well described. Methods Retrospective analysis of patients referred by the emergency department (ED) to TIA clinic (01/01/2016-12/03/2022), linked to hospital records for electronic follow-up. Only those with Clinical Frailty Scale (CFS) recorded within two weeks of clinic were included. Prevalence of frailty was determined based on CFS score >4. Hazard ratios (HR) for mortality were determined through Cox proportional hazard regression, adjusted for prognostic factors. Where repeat CFS data were available, temporal change in frailty was recorded (~15 months). Results Of 1185 patients included, 53.5% (n=634) had frailty. Patients with frailty tended to be older (median age 81 vs 74 years, p<0.001) and female (53.9% vs 39.9% p<0.001). Of 335 diagnosed with TIA following review, 61.2% (n=205) were frail. Prevalence of frailty by clinic diagnosis was: TIA 61.2% (205/335); stroke 46.7% (128/274); other diagnoses 52.3% (301/575). In TIA patients and the whole cohort (WC), frailty (TIA:HR:2.69 [95%CI:1.23-5.87, p=0.013], WC:2.58 [95%CI:1.64-4.08, p<0.001]) and increasing age [HR:1.07 95%CI:1.04-1.12], were predictive of mortality. In stroke patients, only increasing age was predictive of death (HR:1.11 [95%CI:1.04-1.19, p=0.003]). Of 414 patients with repeat CFS, median interval 15 months, median change was +1 point (IQR:0-2). Conclusion Frailty is common in TIA and becomes more common following TIA. Strength of association of frailty with poor outcome was greater for TIA patients than for those with stroke. Routine assessment of frailty may be a useful addition to TIA services.