Multiple Stroke Risk Factors Research Articles

Exploring clinical indicator variations in stroke patients with multiple risk factors: focus on hypertension and inflammatory reactions

BackgroundStroke stands as the second leading cause of death worldwide. Currently, extensive research has been conducted on stroke risk factors. However, when stroke patients contend with multiple risk factors, the impact on clinical indicators remains uncertain.ObjectivesThis study seeks to investigate potential significant variations among distinct ranges of clinical indicators in instances where stroke patients experience multiple risk factors and various ischemic stroke subtypes.Material and methodsThe research encompassed 440 stroke patients admitted to the First People's Hospital of Wenling City, Zhejiang Province, China. These patients were classified based on the type and quantity of risk factors and subtypes of ischemic stroke they presented. The χ2 test was employed to assess the relationship between the risk of comorbid diseases and clinical indicators in stroke patients.ResultsThe results of our study have underscored a significant correlation between various comorbid risk factors in stroke patients and the patients' age (P < 0.010). Furthermore, we observed noteworthy disparities in the plasma levels of IL-2, IL-4, IL-6, IL-10, TNF-α, and INF-γ between patients devoid of risk factors and those presenting with comorbid risk factors associated with stroke. Significant differences in INF-γ were observed between the two subtypes of ischemic stroke, namely lacunar infarction and cardioembolic stroke.ConclusionAge is correlated with an elevated risk of stroke. Individuals exhibiting multiple stroke risk factors and diverse ischemic stroke subtypes commonly present with abnormal lipid levels and imbalances in Th1/Th2 cytokines. These factors significantly contribute to the onset and progression of stroke. Furthermore, inflammatory responses, particularly those induced by atherosclerosis, play a pivotal role in the genesis of stroke and exert a substantial influence on its prognosis.

The Mediterranean Soul Food Diet Intervention After Stroke, a Feasibility Study in the Stroke Belt

The Mediterranean diet has positive effects on primary and secondary prevention of cardiovascular disease including stroke, yet dietary counseling to stroke patients is under-utilized. This study aimed to develop a culturally adapted Mediterranean diet and introduce it to patients admitted to the hospital for acute ischemic stroke with at least one metabolic risk factor (type 2 diabetes mellitus [DM], hypertension [HTN], high low-density lipoprotein [LDL], low high-density lipoprotein [HDL], and/or body mass index [BMI] &gt; 25). Dietary adherence and nutritional knowledge were measured at baseline and 30, 90, and 120 days post-stroke. Weight, hemoglobin A1C [HbA1C], and triglycerides [TG] were assessed at baseline and follow-up. The study enrolled 54 participants, 50 of whom had sufficient data for analysis. Dietary adherence and nutritional knowledge scores increased in 76.4% of participants, with a statistically significant median increase for each. Additionally, participants had significantly lower weight, HbA1C, and TG at follow-up than baseline. This study showcases the potential to introduce a culturally appropriate Mediterranean diet at the point-of-care, and significantly influence dietary adherence and nutritional knowledge and multiple stroke risk factors.

Demographics, Risk Factors, and Etiology of Posterior Cerebral Artery Stroke Causing Homonymous Hemianopia.

Posterior cerebral artery (PCA) strokes account for up to 10% of all ischemic strokes, often presenting with homonymous hemianopia. The proportion of these strokes attributed to various etiologies varies widely in previously published studies, owing largely to differing patient populations, definitions of stroke pathogenesis, and vascular territories involved. The Causative Classification System (CCS), an automated version of the Stop Stroke Study (SSS) Trial of Org 10,172 in Acute Stroke Treatment (TOAST) system, allows for a more rigorous assignment of stroke etiology. We excerpted clinical and imaging data on 85 patients who had PCA stroke with homonymous hemianopia examined at the University of Michigan. We compared the stroke risk factor profile of our PCA cohort with that of 135 patients with stroke in the distribution of the internal carotid artery (ICA) and middle cerebral artery (MCA) in an unpublished University of Michigan registry. We applied the CCS web-based calculator to our PCA cohort to determine stroke etiology. In our PCA cohort, 80.0% had at least 2 conventional stroke risk factors and 30.6% had 4 risk factors, most commonly systemic hypertension. The risk factor profile of our PCA cohort resembled that of our ICA/MCA cohort except that the mean age of our PCA cohort was more than a decade younger and had a significantly lower frequency of atrial fibrillation (AF) than our ICA/MCA cohort. In nearly half of the patients with AF in our PCA cohort, AF was diagnosed after the stroke. Among stroke etiologies in our PCA cohort, 40.0% were of undetermined cause, 30.6% were from cardioaortic embolism, 17.6% were from other determined causes, and only 11.8% were from supra-aortic large artery atherosclerosis. Strokes after endovascular or surgical interventions were prominent among other determined causes. Most patients in our PCA cohort had multiple conventional stroke risk factors, a finding not previously documented. Mean age at stroke onset and AF frequency were lower than in our ICA/MCA cohort, in agreement with previous studies. As some other studies have found, nearly 1/3 of strokes were attributed to cardioaortic embolism. Within that group, AF was often a poststroke diagnosis, a finding not previously highlighted. Compared with earlier studies, a relatively high portion of strokes were of undetermined etiology and of other determined etiologies, including stroke after endovascular or surgical interventions. Supra-aortic large artery atherosclerosis was a relatively uncommon explanation for stroke.

The great masquerader: recurrent ischemic strokes secondary to meningo-vascular syphilis in a 62-year-old patient with stroke risk factors (P12-5.019)

<h3>Objective:</h3> N/A <h3>Background:</h3> Syphilis is a debilitating multisystem disease resulting from infection with the spirochete Treponema pallidum. Even though it is uncommon, it is a great mimic of stroke and is misdiagnosed almost 80% of the time. It commonly involves the middle cerebral artery and basilar or anterior spinal artery territories. 4% of patients with recurrent strokes can have syphilis. We present a patient with a recurrent stroke due to meningo-vascular syphilis (MVS). <h3>Design/Methods:</h3> A 62-year-old male with hypertension, hyperlipidemia, diabetes, and coronary artery disease presented with confusion and word-finding difficulty, and was found to have an acute ischemic stroke in the right basal ganglia (BG). The patient was discharged on dual anti-platelet therapy and statin for secondary stroke prevention. As a part of the stroke workup, he was found to be highly reactive for rapid plasma regain, and the subsequent fluorescent treponemal antibody absorption test was reactive with the diagnosis of syphilis. He presented again 3 weeks later with transient facial paralysis. The cerebrospinal fluid was positive for a Venereal Disease Research Laboratory test, indicative of MVS. He received 4 million units of penicillin every 4 hours intravenously for 14 days with improvement in symptoms and no further recurrence of strokes. <h3>Results:</h3> N/A <h3>Conclusions:</h3> Our patient presented with acute ischemic infarct in BG, etiology thought to be small vessel disease in the setting of multiple stroke risk factors. Meningo-vascular syphilis, a subtype of neurosyphilis, can cause recurrent ischemic strokes. While uncommon, neurosyphilis remains prevalent in the United States and is often misdiagnosed because of its heterogenous clinical features. Syphilis screening is usually considered in young patients with a prior documented history of sexually transmitted disease however it is prudent that patients with recurrent strokes might benefit from routine screening tests for syphilis, regardless of age group or the presence of stroke risk factors. <b>Disclosure:</b> Dr. Waheed has nothing to disclose. Dr. Carranza-Renteria has nothing to disclose. Dr. Yousuf has nothing to disclose.

Differences in Multiple Risk Factors Between Black and White Individuals With Young-Onset Ischemic Stroke.

Stroke in young adults constitutes 15%-18% of all ischemic stroke cases. Black individuals have an excess risk of ischemic stroke especially in young adults. Although it is known that Black patients have a higher prevalence of hypertension and diabetes, few studies have addressed the association of concurrent multiple vascular risk factors with the excess risk of early-onset stroke among Black individuals. A population-based case-control study of early-onset ischemic stroke, ages 15-49 years, was conducted in the Baltimore-Washington DC region between 1992 and 2007. Presence of the risk factors of obesity, hypertension, diabetes, and current smoking were obtained from both cases and controls by an in-person interview. Risk factor groups were defined as (1) 1 risk factor, (2) 2 risk factors, (3) 3 risk factors, and (4) 4 risk factors. Logistic regression analysis adjusting for age and sex was used to evaluate the association between each risk factor group and ischemic stroke compared with the reference group with no risk factors. The study included 1,034 cases and 1,091 controls. Of the cases, 47% were Black, 54% were men, and the mean (±SD) age was 41.0 (±6.9) years. The odds of having a stroke increased exponentially as the number of risk factors increased, 2.1, 2.6, 7.6, 16.5, all p < 0.001, for groups 1-4, respectively. When stratified by race, Black individuals were approximately 6 times more likely to have all 4 risk factors. The risk of stroke in young adults increased exponentially with the number of risk factors. Young Black patients with ischemic stroke were approximately 6 times more likely to have the co-occurrence of obesity, hypertension, diabetes, and smoking compared with their White counterparts. Targeting public health interventions to identify and improve care to Black young adults with multiple stroke risk factors may have substantial impact on lowering risk of stroke.

Prevention paradox between stroke and multiple potential risk factors using data from a population-based cohort study

Previous studies have found the prevention paradox in the association between stroke events and a single specific risk factor, indicating that a population-based strategy may be more effective than a high-risk-based strategy for prevention. We tested the hypothesis that the prevention paradox does not apply when focusing on multiple potential risk factors simultaneously. The study cohort included 9051 individuals from Japan aged 40–89 years. The time-dependent Cox proportional-hazards models were used to identify the primary risk factor associated with stroke onset. We classified participants based on risk factors in two distinct ways: 1) classifying the high-risk group participants according to a single specific risk factor that had a large association with stroke in both sexes and all ages and 2) classifying the high-risk group participants according to 1–3 risk factor(s) including hypertension, hyperglycemia, and/or dyslipidemia. Then, we compared the proportions of the total number of participants who developed stroke in both groups to assess the prevention paradox. We found that hypertension was a primary risk factor for stroke incidence, regardless of sex and age. The percentage of patients with a single specific risk of and developed stroke was 46%–63%, while the percentage of patients with 1–3 risk factor(s) was 71–83%. This finding leads to the conclusion that the prevention paradox does not hold when multiple stroke risk factors were associated, suggesting that a high-risk-based strategy that focuses on patients with multiple risk factors may be more effective in preventing strokes.

"Pill-in-Pocket" Anticoagulation for Atrial Fibrillation: Fiction, Fact, or Foolish?

"Pill-in-Pocket" Anticoagulation for Atrial Fibrillation: Fiction, Fact, or Foolish?

Sleep apnea prediction in acute ischemic stroke (SLAPS score): a derivation study

BackgroundDespite its high prevalence and negative impact, sleep-disordered breathing (SDB) remain commonly underdiagnosed and undertreated in stroke subjects. Multiple stroke comorbidities and risk factors, including obesity, hypertension, diabetes mellitus, ischemic heart disease, atrial fibrillation, and heart failure (H.F.) have been associated with SDB. This study aimed to examine associations of clinical and demographic characteristics with moderate-to-severe SDB (msSDB) in stroke patients and to develop a predictive score. MethodsConsecutive patients with ischemic stroke were enrolled in an open, prospective study. SDB was assessed using standard polysomnography. Clinical and demographic characteristics, as well as findings from echocardiography, entered the analysis. Multivariate logistic regression models were used to examine the associations with msSDB. Based on the results, an original score to predict msSDB was proposed and tested. Results120 patients with acute ischemic stroke (mean age: 64.0 ± 12.2 years, median NIHSS: 4) were included. Body-mass index (BMI), wake-up stroke onset (WUS), and diastolic dysfunction were independently associated with msSDB. A score allocating 1 point for BMI≥25 kg/m2 and <30 kg/m2, 2 points for BMI≥30 kg/m2, 1 point for WUS and 1 point for diastolic dysfunction resulted in an area under the curve of 0.81 (95% CI 0.71–0.90, p<0.001), sensitivity 82.9%, specificity 71.9% to identify stroke patients with msSDB. ConclusionsBMI, WUS, and diastolic dysfunction were associated with msSDB. A simple score might help to identify acute stroke patients with msSDB, who are usual candidates for positive airway pressure therapy.

Identification of pleiotropic genes between risk factors of stroke by multivariate metaCCA analysis.

Genome-wide association studies (GWASs) have identified more than 20 genetic loci as risk predictors associated with stroke. However, these studies were generally performed for single-trait and failed to consider the pleiotropic effects of these risk genes among the multiple risk factors for stroke. In this study, we applied a novel metaCCA method followed by gene-based VEGAS2 analysis to identify the risk genes for stroke that may overlap between seven correlated risk factors (including atrial fibrillation, hypertension, coronary artery disease, heart failure, diabetes, body mass index, and total cholesterol level) by integrating seven corresponding GWAS data. We detected 20 potential pleiotropic genes that may be associated with multiple risk factors of stroke. Furthermore, using gene-to-trait pathway analysis, we suggested six potential risk genes (FUT8, GMIP, PLA2G6, PDE3A, SMARCA4, SKAPT) that may affect ischemic or hemorrhage stroke through multiple intermediate factors such as MAPK family. These findings provide novel insight into the genetic determinants contributing to the concurrent development of biological conditions that may influence stroke susceptibility, and also indicate some potential therapeutic targets that can be further studied for the prevention of cerebrovascular disease.

Migraine and Ischemic Stroke in Women. A Narrative Review

Migraine is associated with ischemic stroke. Women are 3-fold as likely as men to have migraine, and high estrogen states increase the risk of migraine with aura (MWA), venous thromboembolism (VTE), and of stroke.We review the epidemiological and mechanistic evidence of the migraine-stroke relationship and its risk factors, with a focus on women and conditions that exclusively or predominantly affect them. METHODS: We performeda search of MEDLINE/PubMed database, then a narrativereview ofthe epidemiological evidence of the migraine-stroke relationship as well as the evidence forarterial, thrombophilic, and cardiac mechanisms to explain this connection. We examinethe implications of this evidencefor thediagnostic evaluation and treatmentof MWA. MWA is associated with multiple stroke risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, atrial fibrillation, and patent foramen ovale. In women, MWA is also associated with biomarkers of endothelial activation, hormonal contraceptive use, pregnancy, and VTE. This suggests that a subset of auras may be secondary, that is, induced by ischemia related to microemboli or in situ thrombosis. MWA-associated ischemic stroke is more common in young (<45years old) women with high frequency of migraine attacks, hormonal contraception use, and with pregnancy and preeclampsia. There is increasing evidence that cardioembolism, often in conjunction with thrombophilia, plays a prominent role in MWA-associated cerebral infarction. The commonality of factors associated with MWA and with MWA-associated stroke suggest that persons with secondary, ischemia-induced aura may be at elevated risk of stroke. Although further research is needed, we recommend consideration of a diagnostic evaluation of MWA that mirrors the evaluation of transient ischemic attack, given that prophylactic treatment targeting the ischemic origin of secondary aura may prevent migraine as well as stroke.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk.

Background and Purpose- Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods- We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results- The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions- A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative.

BackgroundStroke is the third leading cause of death among US Hispanic and non‐Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity.Methods and ResultsData were taken from the Women's Health Initiative Observational Study with follow‐up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow‐up period of 12.6 years. The average age was 63.7 years at baseline. Fifty‐eight percent (n=46 699) reported ever breastfeeding; 83% were non‐Hispanic white, 8% were non‐Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70‐0.83). This association was strongest for non‐Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37‐0.71). Further, breastfeeding for a relatively short duration (1‐6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74‐0.89). This association appeared stronger with longer breastfeeding duration and among non‐Hispanic white and non‐Hispanic black women (test for trend P<0.01).ConclusionsStudy results show an association and dose‐response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Sodium-glucose Cotransporter 2 Inhibitors and Ischemic Stroke.

Type 2 diabetes mellitus (T2DM) is associated with substantially increased risk for cardiovascular events, including ischemic stroke. In turn, ischemic stroke represents a leading cause of mortality and long-term disability worldwide. The recent class of glucose-lowering agents is sodium-glucose cotransporter 2 (SGLT-2) inhibitors, which act through inhibition of glucose reabsorption in the kidney, resulting in glucose excretion without stimulating insulin release. Accumulating data suggests that these agents improve multiple risk factors for ischemic stroke except their glucose-lowering effect. In the present review, the pleiotropic actions of SGLT-2 inhibitors are summarized and their potential implications on ischemic stroke prevention are discussed. We performed a comprehensive search of the literature in terms of SGLT-2 inhibitors efficacy on ischemic stroke and traditional risk factors of cerebrovascular disease. Several studies consistently showed that SGLT-2 inhibitors reduce blood pressure, induce weight loss, increase high-density lipoprotein cholesterol levels and reduce triglyceride levels. In addition, they improve several emerging cardiovascular risk factors, most notably arterial stiffness, albuminuria and oxidative stress. However, in the only trial that evaluated the effects of these agents on the incidence of ischemic stroke, empagliflozin did not reduce the risk of first or recurrent stroke despite a significant reduction in cardiovascular and all-cause mortality. Despite the multiple pleiotropic effects of SGLT-2 inhibitors, these agents do not appear to affect stroke risk. Ongoing large trials with longer follow-up will evaluate whether the pleiotropic effects of this class will translate into benefits in ischemic stroke prevention.

Factors predicting community participation in patients living with stroke, in the Western Cape, South Africa

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa.Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews.Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors.Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients’ participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors.Implications for RehabilitationCommunity participation in the general population of stroke survivors’ is largely determined by their mobility function.Determinants of community participation among stroke survivors essentially vary according to age and gender.Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients’ demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

Baseline Quality of Life and Risk of Stroke in the ALLHAT Study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial).

The visual analogue scale is a self-reported, validated tool to measure quality of life (QoL). Our purpose was to determine whether baseline QoL predicted strokes in the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) and evaluate determinants of poststroke change in QoL. In the ALLHAT study, among the 33 357 patients randomized to treatment arms, 1525 experienced strokes; 1202 (79%) strokes were nonfatal. This study cohort includes 32 318 (97%) subjects who completed the baseline visual analogue scale QoL estimate. QoL was measured on a visual analogue scale and adjusted using a Torrance transformation (transformed QoL [TQoL]). Kaplan-Meier curves and adjusted proportional hazards analyses were used to estimate the effect of TQoL on the risk of stroke, on a continuous scale (0-1) and by quartiles (≤0.81, >0.81≤0.89, >0.89≤0.95, >0.95). We analyzed the change from baseline to first poststroke TQoL using adjusted linear regression. After adjusting for multiple stroke risk factors, the hazard ratio for stroke events for baseline TQoL was 0.93 (95% confidence interval, 0.89-0.98) per 0.1 U increase. The lowest baseline TQoL quartile had a 20% increased stroke risk (hazard ratio=1.20 [95% confidence interval, 1.00-1.44]) compared with the reference highest quartile TQoL. Poststroke TQoL change was significant within all treatment groups (P≤0.001). Multivariate regression analysis revealed that baseline TQoL was the strongest predictor of poststroke TQoL with similar results for the untransformed QoL. The lowest baseline TQoL quartile had a 20% higher stroke risk than the highest quartile. Baseline TQoL was the only factor that predicted poststroke change in TQoL. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Risk of stroke in patients with newly diagnosed multiple myeloma: a retrospective cohort study.

Cerebrovascular events are a common complication among patients with cancer, increasing morbidity and mortality. However, the association between multiple myeloma and cerebrovascular events remains unclear. We therefore investigated multiple myeloma patients' risk factors for stroke to devise a better stroke-prevention strategy. This study includes consecutive patients 20years and older who were newly diagnosed with symptomatic multiple myeloma at Taipei Veterans General Hospital, a tertiary medical center, between January 1, 2002 and December 31, 2014. The primary outcome was stroke development. Patients with head injuries, brain tumors, brain parenchymal invasions, or antecedent malignancies were excluded. Hazard ratios (HRs) of stroke risk factors for multiple myeloma patients were estimated by Cox proportional regression analysis. Overall, 395 patients with a median age of 70years were investigated. In the median follow-up period of 18months, cerebrovascular events occurred in 16 patients, including 10 ischemic strokes and 6 hemorrhagic strokes. The 5-year estimated cumulative incidence rate was 7.45%. In the multivariate analysis, the κ light chain isotype (adjusted HR, 8.37; 95% confidence interval [CI], 1.91-39.8), previous cerebrovascular accidents (adjusted HR, 5.16; 95% CI, 1.48-17.9), and serum creatinine>2mg/dL (adjusted HR, 4.21; 95% CI, 1.10-16.0) were identified as independent risk factors for stroke. Subgroup analysis showed that atrial fibrillation (adjusted HR, 8.07) and previous cerebrovascular accident (adjusted HR, 4.89) are significant risk factors for ischemic stroke. Serum creatinine>2mg/dL (adjusted HR, 30.6) and previous cerebrovascular accident (adjusted HR, 13.9) are significant for hemorrhagic stroke. Moreover, therapeutic strategies for multiple myeloma were not associated with stroke in our study. This study demonstrates that risk of stroke increases in myeloma patients with a κ light chain isotype, previous cerebrovascular events, and renal impairment. Further prospective clinical studies to clarify the relationship between multiple myeloma and stroke are warranted.

Role of atrial fibrillation burden in assessing thromboembolic risk.

Stroke represents the most devastating complication of atrial fibrillation (AF). Our understanding of the pathophysiology of thromboembolism in patients with AF remains incomplete, and as such, our assessment and management of this risk is imperfect. Current guidelines regard the risk of thromboembolism as independent of the frequency or duration of AF.1 Paradoxically, standard practice in the pericardioversion period considers thromboembolic risk to accrue after 48 hours of AF.1 This recommendation, however, is based on limited data, including an observational study of 357 patients which demonstrated that the risk of thromboembolic events was <1% in patients with AF lasting <48 hours who cardioverted without prolonged anticoagulation therapy or a transesophageal echocardiogram.2 No strong randomized control trial data exist to specifically support a 48-hour safety cut-off, and recent data suggest that the duration of AF associated with a significantly increased risk of stroke may in fact be less.3–8 The emergence of technology to allow absolute quantification of the frequency and duration, or burden, of AF offers the opportunity to refine our assessment and management of thromboembolic risk associated with AF. It has been 200 years since William Wood described a ball thrombus in the left atrium of a patient with mitral stenosis9 and 170 years since Virchow identified the critical components required for thrombus formation.10 It took until 1930 for Harvey and Levine to first declare that “auricular fibrillation definitely increases the incidence of auricular thrombosis” in an autopsy series of patients with mural thrombi.11 Uncertainty as to whether nonrheumatic AF resulted in stroke continued for the next 40 plus years until Wolfe and colleagues, in their landmark analysis using the Framingham population data, identified a 5.6-fold increased risk of stroke in patients with chronic nonvalvular AF.12 With time it would become …

Cerebrovascular Accident in a High-Risk Patient During the Early Initiation Phase With Canagliflozin.

To report a case of cerebrovascular accident (CVA) in a high-risk patient following initiation of canagliflozin, the first-in-class sodium-glucose-co-transporter 2 inhibitor approved by the Food and Drug Administration for type 2 diabetes mellitus. We describe a 62-year-old woman, with multiple clinical risk factors for stroke, who began canagliflozin 300 mg daily in addition to basal insulin therapy for diabetes management. The patient developed expressive aphasia 15 days following initiation of canagliflozin. Neuroimaging revealed acute infarcts of the left basal ganglia and temporal and parietal lobes. The patient was diagnosed with a CVA. Canagliflozin therapy was discontinued, metformin therapy was reinitiated in addition to the patient's basal insulin, and the patient was treated with antiplatelet, statin, and speech therapies. Assessment of the cardiovascular (CV) safety of canagliflozin is currently being investigated. A numerical increase in CV events, including nonfatal stroke, has been noted in preliminary data from ongoing analyses of canagliflozin in patients with preexisting CV risk factors. Although significant clinical risk factors were present in the patient described, a workup for routine causality came back negative. According to the Naranjo probability score, initiation of canagliflozin had a possible to probable association with the patient's CVA. This case suggests a potential association between the timing of canagliflozin initiation and development of stroke in patients with multiple clinical risk factors. We advise practitioners to use caution when initiating this new agent in patients at high risk for stroke while long-term CV safety surveillance is ongoing.

Long-term prognosis for hearing recovery in stroke patients presenting vertigo and acute hearing loss

Background and purposeVertebrobasilar ischemic stroke (VBIS) can cause acute hearing loss (AHL) because the vertebrobasilar system supplies most of the auditory system including the inner ear. The aim of this study was to assess the long-term prognosis of AHL associated with VBIS. MethodsOver 12.5years, 62 patients with AHL of a vascular cause who were followed for at least 1year (mean, 49.2months; SD, 24.4months) were enrolled in this study. Quantitative audiovestibular function testing was performed during the acute (mostly within 10days after symptom onset) and last follow-up periods in all patients. ResultsOn the last follow-up, approximately 65% (39/62) of the patients showed a partial (n=24) or complete (n=15) hearing recovery. All but 2 (97%) patients had acute vertigo and 56 (56/62, 90%) had a unilateral canal paresis to caloric stimulation on the side of the AHL. The most commonly infarcted territory on brain MRI was in the distribution of the anterior inferior cerebellar artery (55/62, 89%). Multivariable analysis showed that multiple risk factors for stroke [odds ratio (OR) 10.46, 95% confidence interval (CI) 1.72 to 13.7, p=0.011] and profound hearing loss [OR 3.92, 95% CI 1.03 to 14.97, p<0.046] predicted a poor outcome for recovery of hearing loss. ConclusionsAcute hearing loss associated with posterior circulation ischemic stroke exhibits a relatively good long-term outcome. Two or more risk factors for stroke and profound hearing loss are adverse prognostic factors for recovery of hearing loss of a vascular cause.

A survey of the perceived risk for stroke among community residents in western urban China.

Background and PurposePersons who perceive their risk for stroke can promote the intervention of stroke risk factors and reduce the risk of stroke occurrence. Our purpose was to assess the knowledge of stroke risk factors and the level of perceived risk for stroke.MethodsIn 2011, a population-based face-to-face interview survey was conducted in Yuzhong district, Chongqing. A total of 1500 potential participants aged ≥18 years old were selected using a multi-stage sampling method. The knowledge of stroke risk factors and perceived risk for stroke was surveyed.ResultsA total of 941 participants completed the questionnaire survey. The respondents’ awareness rate of stroke risk factors ranged between 53.3% and 87.2%. The community residents’ perceived risk for stroke was only 17.7%. Multiple logistic regression analysis showed that 45–64 years age group, a history of hypertension, hyperlipidemia, heart disease, and stroke were independent predictors of perceived risk for stroke. Perceived risk for stroke increased as the number of risk factors increased (P<0.001). However, even for respondents with three or more risk factors, only 41% perceived themselves to be at risk for stroke.ConclusionsIn this population-based survey, few community residents perceived risk for stroke, even among those with multiple stroke risk factors, most did not perceive themselves to be at risk for stroke. Persons with 45–64 years old, a history of hypertension, hyperlipidemia, heart disease or stroke were more likely to perceive risk for stroke. The awareness of the risk for stroke has yet to be enhanced among community residents.