Occurrence Of Stroke Research Articles

Left atrioventricular coupling index is an independent associate of new-onset AF and stroke in hypertrophic cardiomyopathy: a CMR study

Abstract Background Left atrial (LA) dysfunction is an important marker of disease progression in hypertrophic cardiomyopathy (HCM). LA volumes and functional parameters are associated with new-onset atrial fibrillation (AF) and its complications including stroke. The association between left atrioventricular coupling (LACI), a parameter reflecting the contribution of the left ventricular and LA remodeling to LA dysfunction, with the occurrence of new-onset AF and stroke has not been evaluated. Aim To investigate the association between LACI and the occurrence of new-onset AF or stroke in patients with HCM. Methods In patients with an established diagnosis of HCM and cardiac magnetic resonance (CMR) data, LACI was calculated as the ratio between the LA and the LV end-diastolic volumes. New-onset AF or occurrence of stroke comprised the primary combined endpoint. Cumulative event-free survival rates for the occurrence of the primary endpoint were estimated with the population divided according to a LACI cut-off value of 40%. The association between clinical and CMR variables and the primary endpoint was assessed with univariable and multivariable Cox proportional hazard regression models. Results Of 114 patients with HCM, (mean age 54±16 years, 33 (29%) female, LV ejection fraction 67.0±8.4%), 71 patients (49%) had a LACI > 40% (left atrioventricular uncoupling). During a median follow-up of 4.1 (1.8-6.4) years, 19 (16.7%) patients experienced new-onset AF or stroke. Patients with preserved left atrioventricular coupling (LACI ≤ 40%) had a lower cumulative rate of events compared to those with left atrioventricular uncoupling (log-rank p=0.031, Fig. 1). LACI was independently associated with new-onset AF or stroke after adjusting by the presence of late gadolinium enhancement (LGE) sex and age (HR=23.27, p=0.016). Conclusions In patients with HCM, the presence of left atrioventricular uncoupling is independently associated with the occurrence of new-onset AF or stroke.

Usefulness of left ventricular mechanical dyssynchrony for predicting atrial fibrillation and adverse outcomes following first atrial fibrillation event

Abstract Background Left ventricular mechanical dyssynchrony (LVMD) has shown to predict many cardiovascular outcomes including ventricular arrhythmias. Our hypothesis is that LVMD can reveal early atrial dysfunction. Purpose The aim of this study was to investigate whether LVMD can be used to predict atrial fibrillation (AF) and adverse outcomes following first AF event in individuals from the general population. Methods A total of 3785 individuals (mean age 55±17 years, 57% women) from the general population free of AF, heart failure (HF) and prior stroke had an echocardiographic examination performed including two-dimensional speckle tracking echocardiography. LVMD was calculated as the standard deviation of the regional time-to-peak strain from the three apical views. The primary endpoint was AF, and the secondary endpoint was complicated AF as assessed by the occurrence of either stroke or HF after the diagnosis of AF. Results During a median follow-up of 5 years (interquartile range, 4.4-6.2 years), 142 (4%) individuals were diagnosed with AF, and of these 22 (15%) individuals developed HF or stroke. LVMD was a univariable predictor of AF (per 10ms increase: HR 1.03; 95% CI (1.02-1.05), p<0.001, Figure). The association remained significant even after multivariable adjustment for age, sex, body mass index, diabetes, hypertension, heart rate, previous ischaemic heart disease, systolic blood pressure, diastolic blood pressure, smoking, left ventricular ejection fraction, global longitudinal strain, left atrial volume index (LAVI), and E/e’ (per 10ms increase: HR 1.02; 95% CI (1.00-1.04), p=0.042). LVMD also predicted complicated AF, and the association remained significant even after multivariable adjustment (per 10ms increase: HR 1.05; 95% CI (1.01-1.09), p=0.026). Furthermore, LVMD provided incremental prognostic information over the LAVI with regard to predicting AF (Harrell’s C-statistics 0.66 vs. 0.70, p=0.012). Conclusion In a low-risk general population, LVMD provides prognostic information on the risk of AF. Additionally, LVMD can identify individuals with complicated AF defined as occurrence of either stroke or HF following the diagnosis of incident AF. Furthermore, LVMD provides incremental prognostic information over the LAVI in predicting AF.

Risk of atrial fibrillation recurrence after new-onset transient episode during ST-elevation myocardial infarction

Abstract Background Atrial fibrillation (AF) often complicates ST-elevation myocardial infarction (STEMI) and is associated with major in-hospital complications and increased mortality. The data on AF recurrence after new-onset transient STEMI-associated AF is scarce, and electrocardiographic (ECG) predictors of AF recurrence are unknown. Purpose Our aim was to assess the risk of AF recurrence and to find out the predictors of AF recurrence after transient STEMI-associated AF. Methods STEMI patients admitted during 2007-2010 for primary percutaneous coronary interventions (PCI) were followed up until 2018. All ECGs ever recorded before, during or after STEMI (n=58907) were exported from regional database in digital format and processed using Glasgow algorithm. Clinical characteristics and mortality status were retrieved from the Swedish national registries. Information regarding AF was obtained from the national registries and the regional ECG database. STEMI-associated AF was defined as first-ever AF episode occurring between symptom onset and hospital discharge. Patients with pre-existing AF, AF after acute coronary artery bypass surgery and patients discharged with ongoing AF were excluded from analysis. P-wave indexes were assessed from the latest sinus rhythm ECG before discharge. The primary endpoint was the first documented AF episode after discharge. The secondary endpoints were total mortality and ischemic stroke. Cox regression analysis was adjusted for relevant clinical covariates. Results 1) 1956 patients who were discharged alive on sinus rhythm were included in the analysis (age 65±12, 70% males), 127(6.5%) of them had transient STEMI-associated AF. 2) Patients with STEMI-associated AF were more likely to develop AF during follow-up (n=74 [58.3%]) than patients without AF before or during STEMI (No AF) (n=56 [3.1%], HR=4.80 95%CI 3.93-5.97) (Figure 1). 3) None of the clinical and demographic characteristics was associated with AF recurrence. P-wave duration, P-terminal force in V1 and P-voltage in lead I were associated with AF recurrence, however only reduced P-wave voltage in lead I <93 µV (75th percentile) (HR=2.29 95% CI 1.21-4.35, p=0.011) remained independently associated with AF recurrence in adjusted analysis (Figure 2). 4) During follow-up, 134 patients had an ischemic stroke and 522 died. STEMI-associated AF was associated with higher long-term mortality risk comparing to No AF (HR=1.18 95%CI 1.02-1.36). The risk of stroke was not associated with STEMI-associated AF (HR=1.08 95%CI 0.79-1.49). In patients with STEMI-associated AF, occurrence of stroke did not differ between patients with and without AF recurrence (5[7%] vs 8 [15%] respectively, p=0.147). Conclusion STEMI-associated transient AF is associated with a 4.8-fold increased risk of AF after discharge, reaching 28% by 1 year after discharge. ECG-based P-wave indexes reflecting atrial remodeling can be used for the prediction of AF recurrence after discharge.

Independent association between radial secondary access and stroke in patients undergoing transcatheter aortic valve implantation

Abstract Background Radial access has become the primary approach for invasive coronary angiography due to its lower complication rate than femoral access. Transcatheter aortic valve implantation (TAVI) frequently requires a secondary access, which has traditionally been femoral access. However, radial access for TAVI is feasible and gaining popularity, but data on its safety and complication rates is still limited. Purpose To evaluate the occurrence of stroke rate in patients undergoing a TAVI procedure with femoral or radial secondary access. Methods A prospective single-center TAVI registry of 2327 patients who received a TAVI procedure between 2019 and 2022 was conducted. All procedures had the primary access over the femoral route. 337 (14.5%) patients had a secondary access over the radial route, whereas 1990 (85.5%) received a femoral secondary access. The primary endpoint was the occurrence of stroke within the hospital stay. Both groups were compared using the t-test or the Mann-Whitney U test according to the distribution of the data. In a second step, a multivariable model was created in which parameters were included that were associated with the endpoint in the previous analysis, as well as parameters that are known to be associated with stroke. Results: Patients were 81.1 ± 6.3 years old, with a Euroscore II of 5.3 ± 6. A total of 610 (26.2%) patients received a balloon-expandable valve. The primary endpoint (stroke within 30 days of the TAVI procedure) was met by 94 (4%) of all patients. Stroke occurred more often in the group with radial secondary access (6.6% (22) vs. 3.6%(72), p = 0.012). Other significant differences between the two groups included (radial vs. femoral access): burden of atrial fibrillation (36.8% vs. 44.6%, p = 0.007), arterial hypertension (87.4% vs. 92%, p = 0.007), Euroscore II (4.6 vs. 5.5, p = 0.006), and frailty (25.2% vs. 40%, p < 0.001). There were no significant differences between the two groups in terms of secondary diagnosis of diabetes or coronary artery disease, age, occurrence of NYHA class III/IV, gender, or cerebral artery disease. In the multivariate analysis including Age, Euroscore II, NYHA class, gender, secondary diagnosis of arterial Hypertension, diabetes or cerebral artery disease, arterial fibrillation, Frailty and radial secondary access, only radial secondary access was independently associated with in-hospital stroke (p = 0.01). Conclusion Radial secondary access was significantly associated with an increased risk of in-hospital stroke following transcatheter aortic valve implantation (TAVI) in our study population. Intense manipulation of the guidewire and catheter to reach the ascending aorta at the beginning of the procedure and to reach the descending aorta for the final angiogram of the primary access vessel may be causative and should be minimized.

Impact of blood pressure control on the risk of stroke and mortality in patients with atrial fibrillation across different ages: a nationwide population-based study

Abstract Background High blood pressure in patients with atrial fibrillation (AF) is strongly associated with adverse outcomes, including stroke and death. The impact of blood pressure (BP) control on stroke and mortality rates among different age groups in patients with AF has not been extensively studied. Purpose To examine the impact of blood pressure on stroke and death in AF patients by age group. Methods Based on data from the Korean National Health Insurance Service database, we enrolled 194,302 patients newly diagnosed with AF between January 2009 and December 2016, who underwent health check-ups within two years. We divided patients into four groups based on age: 40-49 years, 50-59 years, 60-69 years, and 70 years and above, to analyze the primary outcome based on the level of BP control within each group. BP control was categorized into five levels. Patients with systolic BP (SBP)<120 mmHg and diastolic BP (DBP)<80 mmHg (Level 1), 120≤SBP<130 mmHg and DBP<80 mmHg (level 2), 130≤SBP<140 mmHg and 80≤DBP<90 mmHg (Level 3), 140≤SBP<160 mmHg and 90≤DBP<100 mmHg (Level 4), and patients with SBP≥160 mmHg and DBP ≥100 mmHg (Level 5). We also divided patients into five groups based according to their SBP levels. We analyzed the occurrence of stroke and death based on the level of BP control within each age group. Results Among a total of 194,302 patients, 55,142 (28%) were included in Level 1, 24,925 (13 %) in Level 2, 88,020 (46%) in Level 3, 23,179 (12%) in Level 4, and 3,036 (1%) in Level 5, categorized by blood pressure. During a median follow-up of 5.2±2.4 years, 14,409 patients had an incident stroke (incidence rate, 14.2 per 1000 person-years), and 27,230 patients died (incidence rate, 25.8 per 1000 person-years). The lowest incidence of stroke was in the group with 120≤SBP<130 mmHg and DBP<80 mmHg (Level 2) across most age groups (Figure). Stroke risk significantly increased with BP levels above 160/100 mmHg, and BP≥140/90 mmHg was associated with stroke occurrence from the age of 50 onwards. Higher SBP (160 mmHg) was consistently associated with a higher incidence of stroke across all ages (HR 1.32, 95% confidence interval (CI) 1.22-1.43 compared to SBP<100 mmHg). Mortality incidence was also lowest in Level 2, and a trend of gradually increasing mortality was observed as BP levels rise above this level. (Figure). Especially when SBP exceeded 160 mmHg, the probability of death also significantly increased across all age groups below 70 years old. Conclusion Uncontrolled hypertension (especially SBP>160 mmHg) was associated with higher risks of stroke and mortality in patients with AF. This association is notably more significant in the middle-aged group, specifically those between 40 and 59 years old, compared to older age groups. Therefore, particularly in middle-aged groups, it is crucial to emphasize adequate blood pressure control in patients with AF.Figure_DeathFigure_Stroke

Pharmacologic treatment of hypertension guided by non-invasive haemodynamics in primary care improves blood pressure control

Abstract Background Current guidelines on hypertension (HTN) provide blood pressure (BP) targets and therapeutic algorithms but ignore the potential to treat individual patients according to their haemodynamic profile. We have shown that use of non-invasive haemodynamic information obtained by impedance cardiography (ICG) can improve BP control in the primary care setting. Purpose To investigate whether improved rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement translates into improved clinical outcome measures. Methods Electronic medical records (EMR) were obtained for 14,698 patients from two US primary care groups between 2014 and 2023. ICG was done when BP exceeded 140/90 mmHg. Haemodynamic measurements included mean arterial pressure (MAP), cardiac index (CI), cardiac power index (CPI), total peripheral resistance index (TPRI), stroke index (SI) and heart rate (HR) (Figure 1). Haemodynamic ICG profiles were classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Pharmacological therapy was tailored based on haemodynamic information. Rates of successful BP treatment and the occurrence of myocardial infarction (MI) or stroke were tracked through the EMR. Results Of 14,698 patients, 50% were women, 17% were Black and 17% were aged 18-49 years, 45% aged 50-69 years, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 47%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 24%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). Demographic features were not strongly associated with haemodynamic classification. Within 2-3 years of inclusion, >85% of patient achieved BP control (<140/90 mmHg), which was sustained during follow-up. Over a median (IQR) follow-up of 8 (2016-2023) years, there were 14 (5) MI and 34 (16) strokes. These event rates appear to be lower than those reported in other large cohorts of patients with HTN. Conclusions Treating patients with HTN according to their individual haemodynamic profile is associated with high rates of BP control. Further analysis will determine whether the rates of MI, stroke and death are lower than expected based on the patients baseline risk profile.Haemodynamic Status (ICG Test Results)

Association of contemporary hormonal contraception and the risk of arterial thrombosis

Abstract Background While contemporary hormonal contraception is effective in preventing unwanted pregnancies, its potential link to an increased risk of stroke and myocardial infarction raises safety concerns. Purpose This study aimed to investigate the association between the use of contemporary hormonal contraception and the occurrence of ischemic stroke and myocardial infarction. Methods A nationwide prospective cohort study was conducted, comprising of all Danish women aged 15-49 years without a history of arterial and venous thrombosis, thrombophilia, and cancer from 1996 to 2021. Data on hormonal contraception use, stroke and myocardial infarction diagnoses, and potential confounders were collected from nationwide registers. A Poisson regression analysis was performed adjusting for age, education level, calendar year, hypertension, statin use, diabetes, and atrial fibrillation. Results The study followed 2,205,794 women over 23,700,659 person-years. Weighted median age was 33 (interquartile range (IQR): 24-41) for non-users and 25 (20-34) for users. A total of 5,346 ischemic strokes (22.6 per 100,000 person-years) and 2,351 myocardial infarctions (9.9 per 100,000 person-years) occurred during the study period. When compared to no use, oral contraceptives containing ethinyl estradiol at a dose of 30 to 40 μg was associated with the following adjusted incidence rate ratios (and 95% confidence intervals) for ischemic stroke and myocardial infarction, according to progestin type: levonorgestrel, 1.9 (1.7 to 2.2) and 2.0 (1.7 to 2.4); norgestimate, 1.9 (1.5 to 2.3) and 1.9 (1.4 to 2.6); desogestrel, 2.4 (2.0 to 2.9) and 2.2 (1.6 to 3.0); gestodene, 1.9 (1.7 to 2.2) and 1.9 (1.5 to 2.2); drospirenone, 2.0 (1.6 to 2.5) and 1.8 (1.1 to 2.8); cyproterone acetate, 1.7 (1.2 to 2.3) and 2.1 (1.3 to 3.4), respectively. At a dose of 20 μg of ethinyl estradiol, the incidence rate ratios for ischemic stroke and myocardial infarction varied based on the type of progestin as follows: desogestrel, 1.9 (1.6 to 2.2) and 1.4 (1.0 to 1.9); gestodene, 1.7 (1.4 to 2.0) and 1.7 (1.2 to 2.4); drospirenone, 1.4 (0.7 to 2.6) and 1.1 (0.3 to 4.4); For transdermal patch, the incidence rate ratio was 3.4 (1.4 to 8.2) and 0.0 (0.0 to 0.0); for vaginal ring, 2.2 (1.4 to 3.3) and 3.2 (1.7 to 6.3); for intrauterine device, 1.1 (0.9 to 1.2) and 1.1 (0.9 to 1.3); for implant, 2.0 (1.2 to 3.5) and 1.3 (0.4 to 3.9); for injection, 1.9 (0.9 to 3.8) and 0.6 (0.1 to 4.0). Conclusion Use of contemporary hormonal contraception appeared to be associated with ischemic stroke and myocardial infarction when compared to non-users. The incidence rate ratios varied across type of hormonal contraception, estrogen dose, progestin type and route of administration. The findings underscore the importance of informed decision-making when considering contraceptive options, with implications for public health and individual health choices.FlowchartAdjusted incidence rate ratios

The effect of 2 years COVID-19 pandemic on myocardial infarction and stroke admissions: nationwide registry study, sex differences and mortality

Abstract Background Throughout the COVID-19 pandemic many countries reported a decline in myocardial infarction (MI) and stroke admissions. Factors leading to the decline remain uncertain. Purpose In this nationwide study spanning the first two years of the COVID-19 pandemic we evaluated the changes in MI and stroke admissions as the effect of pandemic intensity and nationwide lockdown. We also investigated sex and age differences. We benefited from the fact that the Czech Republic had both, the lowest and one of the highest COVID-19 incidence. Methods We compared the first (March 1, 2020, to February 28, 2021) and the second (March 1, 2021, to February 28, 2022) pandemic years overall and during the COVID-19 waves with the preceding year (March 1, 2019, to February 28, 2020). The occurrence of MI and stroke, patient characteristics, and mortality data were obtained from two nationwide registers covering every hospitalization and every death in the Czech Republic. Results During the first and second pandemic year as compared to the preceding year there were 13,856 and 14,123 vs 15,499 MI admissions, representing a -10,6% (p<0.001) and -8,9% (p<0.001) decline; and 23,194 and 23,231 vs 25,046 stroke admissions, representing a -7.4% (p<0.001) and -7.2% (p<0.001) decline respectively. The significant decline appeared in both MI and stroke in all COVID-19 waves (spring 2020, spring 2021, autumn 2020/winter 2021, -autumn 2021/winter 2022). The greatest MI hospitalization decline (-16%) occurred during the first strict national lock down, during the first COVID-19 wave (spring 2020), the pandemic wave with the lowest COVID-19 incidence. Both, MI and stroke admissions reversed to pre-pandemic numbers during the summer (2020, 2021) when most lockdown restrictions were lifted. The decline in MI was greater in women than in men during both the first (-11.8%, -10%; p<0.001) and second (-10.8%, -7.9%; p<0.001) pandemic years, also for stroke in women greater than in men during the first (-9%, -5.9%; p<0.001) and second (-9.7%, -4.8%; p<0.001) pandemic years. The 30-day all-cause mortality in patients with MI was higher during the first (10.6%; p<0.001) but not the second (9.6%; p=0.34) pandemic year as compared to the preceding year (9.3%), whereas the 30-day mortality in patients with stroke remained unchanged. Conclusions There was a decline in both MI and stroke admissions during the first two years of the pandemic, but such decline was not related to COVID-19 incidence. The greatest reduction in both, MI and stroke admissions, appeared during the first lockdown in the first COVID-19 wave (spring 2020), the period of the lowest COVID-19 incidence. Moreover, the decline in MI and stroke admissions was greater in women. This highlights potential sex differences in health effect. Health authorities should be aware of these findings, in order to adapt their message and restriction measures in case of future major epidemics.Myocardial infarction casesStroke cases

Multiomics Profiling of Plasma Reveals Molecular Alterations Prior to a Diagnosis with Stroke Among Chinese Hypertension Patients.

We aimed to investigate the correlation between plasma proteins and metabolites and the occurrence of future strokes using mass spectrometry and bioinformatics as well as to identify other biomarkers that could predict stroke risk in hypertensive patients. In a nested case-control study, baseline plasma samples were collected from 50 hypertensive subjects who developed stroke and 50 gender-, age- and body mass index-matched controls. Plasma untargeted metabolomics and data independent acquisition-based proteomics analysis were performed in hypertensive patients, and 19 metabolites and 111 proteins were found to be differentially expressed. Integrative analyses revealed that molecular changes in plasma indicated dysregulation of protein digestion and absorption, salivary secretion, and regulation of actin cytoskeleton, along with significant metabolic suppression. C4BPA, Caprolactam, Col15A1, and HBB were identified as predictors of stroke occurrence, and the Support Vector Machines (SVM) model was determined to be the optimal predictive model by integrating six machine-learning classification models. The SVM model showed strong performance in both the internal validation set (area under the curve [AUC]: 0.977, 95% confidence interval [CI]: 0.941-1.000) and the external independent validation set (AUC: 0.973, 95% CI: 0.921-0.999).

A new heart transplant resource: DBD donor with out-of-hospital cardiac arrest

Abstract The aim of the present study is to analyze the differences in terms of cardiac transplant survival in organ recipients from a DBD (donor with brain death) donor characterized by out-of-hospital cardiac arrest (OHCA) and from a DBD donor not characterized by OHCA, in order to find new strategies to expand the donor pool. We analyzed the differences in mortality 30 days and 120 days after transplantation between the two groups of recipients, the length of stay in the ICU, the length of post-operative stay in the hospital, mechanical ventilation, the use of ECMO, the use of CVVH and the possible occurrence of ischemic and/or haemorrhagic stroke. 78 patients were compared: 13 recipients from a donor with OHCA with an average age of 55.18 (44.35 - 63.1) and 65 recipients from a donor without OHCA with an average age of 57.74 (50.9 - 66). The populations under study presented almost the same characteristics in terms of initial diagnosis, risk factors, comorbidities and list status. Comparing the results, no statistically significant differences were found between the two groups for ICU stay (p=1.000), for in-hospital stay (p=0.920) and for mechanical ventilation (p=0.95 ). No statistically significant difference was detected between the two groups even in terms of ECMO support (p=0.90), ischemic stroke (p=0.70), hemorrhagic stroke (p=0.781). From the analysis of the survival curves it can be seen that there is no statistically significant difference between the two groups either with regard to 30-day mortality (p=0.905) or 120-day mortality (p=0.957). The use of a DBD donor with OHCA represents a valid resource in the field of heart transplantation. In the present study it does not affect the recipient's survival rate. 30 days after heart transplantation mortality is conditioned by the intrinsic characteristics of the recipients.Kaplan-Meier 30 day survivalKaplan-Meier 30 day survival

The influence of remnant cholesterol on ischemic stroke and its subtypes

Abstract Background Established studies have firmly identified elevated low-density lipoprotein (LDL) as a key risk factor for stroke. Nevertheless, an emerging body of evidence suggests that residual stroke risk endures even with rigorous LDL control. Recent investigations propose a potential pivotal role of remnant cholesterol (RC) in this lingering risk. However, the causative relationship between RC and ischemic stroke, encompassing its subtypes, remains elusive. In this study, we employed a two-sample Mendelian Randomization (MR) analysis to delve into the causal association between RC and ischemic stroke, aiming to shed light on its various subtypes. Methods We sourced single nucleotide polymorphism (SNP) data associated with stroke and its subtypes from the MEGASTROKE consortium's comprehensive genome-wide association study (GWAS). SNPs relevant to RC were acquired from the MRC Integrative Epidemiology Unit (IEU) Open GWAS database. Our investigation involved the evaluation of the correlation between RC and ischemic stroke, encompassing 40,585 patients and 406,111 controls. Subtypes considered included large artery atherosclerosis (n=4,373), small artery occlusion (n=5,386), and cardioembolic stroke (n=7,193). A meticulous screening process was implemented to select instrumental variables (IVs) for RC, followed by five Mendelian Randomization (MR) analyses utilizing inverse-variance-weighted (IVW), weighted median, MR-Egger regression, simple mode, and weighted mode methods. Rigorous sensitivity analyses, along with assessments for heterogeneity and pleiotropy, were conducted to ensure the robustness and credibility of our study results. Results Our investigation unveiled a causal relationship between RC and large artery atherosclerosis-type ischemic stroke (IVW method, OR=1.267, 95% CI: 1.017-1.578, P=0.035). This association was further substantiated through rigorous sensitivity analyses, assessments for heterogeneity, and pleiotropy tests. In contrast, no evidence supported a causal link between RC and overall ischemic stroke (IVW method, OR=1.072, 95% CI: 0.986-1.164, P=0.102), small artery occlusion-type stroke (IVW method, OR=1.127, 95% CI: 0.939-1.353, P=0.198), and cardioembolic stroke (IVW method, OR=1.083, 95% CI: 0.931-1.259, P=0.301). Conclusions Our findings robustly establish a causal connection between elevated levels of RC and the occurrence of large artery strokes. This highlights the potential efficacy of reducing RC as a preventive strategy against large artery atherosclerosis. Nevertheless, it is crucial to note that such mitigation efforts may not necessarily result in a decreased risk associated with small artery occlusion and cardioembolic strokes.

Impact of protruding and ulcerated aortic atheroma on periprocedural ischemic stroke in patients undergoing transcatheter aortic valve replacement: a comprehensive analysis

Abstract Backgrounds Aortic atherosclerosis has the potential to impact both the strategy and outcomes of transcatheter aortic valve replacement (TAVR). Past research has established a correlation between the thickness and volume of aortic atheroma with periprocedural ischemic stroke and long-term mortality. However, there is limited investigation into the relationship between the morphology of aortic atheroma and outcomes following TAVR. Purpose The study aimed to assess the influence of protruding and ulcerated aortic atheroma on the occurrence of periprocedural ischemic stroke following TAVR. Methods A total of 979 patients who underwent TAVR between February 2012 and May 2019, and had retrospectively available data from contrast-enhanced computed tomography, were included in this analysis. The presence of protruding or ulcerated atheroma was evaluated across four aortic segments: ascending aorta, aortic arch, descending aorta, and abdominal aorta. Protruding aortic atheroma was defined as atheroma with a thickness exceeding 3 mm and protruding components. Ulcerated aortic atheroma was defined as atheroma presenting with ulcer-like disruption of the intima. The primary endpoint assessed was periprocedural ischemic stroke occurring within 48 hours following TAVR. Results The frequencies of protruding and ulcerated aortic atheroma were as follows: 0.2% in the ascending aorta, 6.5% in the aortic arch, 11.1% in the descending aorta, 15.7% in the abdominal aorta, and 24.2% in the entire aorta (Figure 1). Among the 979 patients analyzed, 25 (2.6%) experienced periprocedural ischemic stroke. Patients with protruding or ulcerated aortic atheroma exhibited a significantly higher incidence of periprocedural ischemic stroke compared to those without (5.5% vs. 1.6%, p=0.0010). Multivariate logistic analysis revealed that protruding or ulcerated aortic atheroma, particularly in the aortic arch, independently increased the risk of periprocedural ischemic stroke. (Table 1). Among the subset of patients (309, 34%) undergoing transfemoral TAVR (TF-TAVR) with a self-expandable valve, those with protruding or ulcerated aortic atheroma had a notably higher incidence of periprocedural ischemic stroke compared to those without (9.6% vs. 1.6%, p=0.0083). Conversely, among patients (587, 66%) undergoing TF-TAVR with a balloon-expandable valve, there was no statistically significant difference in the incidence of periprocedural ischemic stroke between those with and without protruding or ulcerated aortic atheroma (4.2% vs. 1.8%, p=0.102). Conclusions Protruding and ulcerated aortic atheroma, particularly in the aortic arch, were linked to a higher risk of periprocedural ischemic stroke post-TAVR. Consequently, careful selection of TAVR strategy, including valve type and procedural approach, is essential for patients with such aortic lesions.Figure 1Table 1

High physical activity relates to higher risk of incident carotid plaque components

Abstract Background The rupture of carotid atherosclerotic plaque, primarily driven by plaque components, is among the leading causes of ischemic stroke. Although physical activity (PA) stands as a major modifiable target for prevention of atherosclerotic diseases, recent studies suggested a potential adverse impact of high-volume PA on atherosclerotic plaque burden in athletes. Data remains scarce from the community-dwelling population regarding to the impact of PA on the longitudinal change of carotid plaque components. Objectives To assess the association between PA and the incidence of carotid plaque components and explore whether the association of PA with stroke and all-cause mortality differs by the presence of plaque components. Methods Between 2007 and 2012, in a community- dwelling cohort in Netherlands, 1327 stroke-free persons (mean ± standard deviation age 72 ± 9 years, 45% women) with carotid atherosclerosis (carotid intima-media thickness > 2.5 mm) were invited for magnetic resonance imaging (MRI) to assess carotid plaque components. From these, 696 persons (1267 carotid arteries) underwent a follow-up MRI between 2014 and 2017 (median between-scan interval 6 years). Carotid plaque components included calcification, intraplaque hemorrhage (IPH), and lipid-rich necrotic core (LRNC). The volume of moderate, vigorous and total PA (unit: metabolic equivalent task hour, MET-h) was assessed using LASA Physical Activity Questionnaires around the time of the first MRI scan. Participants were followed for the occurrence of stroke or all-cause mortality until December 31, 2019. Generalized estimation equation and Cox regression models were used in the analyses, with adjustments for plaque size and other cardiovascular risk factors. Results Compared to lowest quintile PA group, participants in the highest quintile total PA group had a higher risk of new onset of plaque components, odds ratio (95%CI) 2.69 (1.21; 5.94) for calcification, 1.35 (0.82; 2.24) for LRNC and 1.93 (1.12; 3.34) for IPH (Figure 1). Similar associations were observed for vigorous PA but not for moderate PA. Over a median follow-up of 9.5 years, 118 persons suffered a stroke and 298 died. As shown in table 1, baseline IPH, rather than LRNC or calcification, modulated the associations of PA with stroke and all-cause mortality (P-interaction <0.05): higher total PA was associated with a lower risk of stroke among IPH-free persons, with the hazard ratio (95% CI) of 0.929 (0.867; 0.996) per 10 MET-h/week increase; no associations between PA and stroke were found among those with IPH. Similar associations were found between vigorous PA and all-cause mortality. Conclusions Among the middle-aged and elderly with subclinical atherosclerosis, high level PA, especially high vigorous PA, may lead to an unstable carotid plaque. The beneficial effect of PA on stroke and all-cause mortality is only among persons with a stable carotid plaque profile, especially without IPH.

Assessing stroke and mortality risk in heart failure: the CHA2DS2-VASc score's prognostic value in patients with and without atrial fibrillation - a systematic review and meta analysis

Abstract Background Heart failure (HF) is a common cardiovascular disorder that is linked to substantial morbidity and mortality. The CHA2DS2-VASc score, originally designed to assess the risk of stroke in patients with atrial fibrillation, has demonstrated potential as a prognostic indicator for adverse outcomes in patients with heart failure. This systematic review and meta-analysis aimed to assess the predictive accuracy of the CHA2DS2-VASc score in determining the occurrence of stroke and increased mortality rates in patients with heart failure. Methods A thorough search of electronic databases, such as PubMed, EMBASE, and the Cochrane Library, was performed to find pertinent papers published until the search cutoff date. Included studies examined the correlation between the CHA2DS2-VASc score and the likelihood of stroke or death in patients with heart failure. The assessment of the quality of the included studies was conducted using recognized criteria, and data were collected for quantitative synthesis. Findings The meta-analysis encompassed four studies (45864 patients), revealing a consistent and substantial correlation between elevated CHA2DS2-VASc scores and heightened risks of both stroke and mortality in heart failure patients. More precisely, patients with CHA2DS2-VASc scores ≥4 had a greater risk of stroke compared to those with scores <4 (odds ratio 0.38, 95% confidence interval 0.33-0.43, p-value < 0.00001). The combined data showed homogeneity (p-value = 0.24, I2 = 29%). Similarly, patients with CHA2DS2-VASc scores ≥4 had a higher risk of mortality compared to those with scores <4 (OR 0.49, 95% CI 0.30-0.80, P = 0.05). However, the combined data showed significant heterogeneity (P < 0.00001, I2 = 96%). Conclusion The CHA2DS2-VASc score is a useful predictive tool for identifying heart failure patients who are hospitalized and at a high risk of both stroke and high mortality. The results of this study provide evidence for the practicality of using the CHA2DS2-VASc score for risk stratification in patients with heart failure. Additional investigation is necessary to confirm these findings and examine the incorporation of the CHA2DS2-VASc score into risk assessment algorithms for tailored patient management.Figure:Risk of strokeFigure:Risk of mortality

Drug-coated balloon versus drug-eluting stent for de novo culprit lesion in acute coronary syndromes: a report from nationwide registry in japan

Abstract Background Randomized trials have demonstrated the non-inferiority of DCB strategy compared to DES strategy for ACS [1-3]. However, generalizability in clinical settings remains unclear. Purpose This study aims to compare the outcomes between drug-coated balloon (DCB) and drug-eluting stent (DES) strategies in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) within a nationwide procedure-based registry. Methods This is a retrospective analysis of a cohort study from a prospective, nationwide registry from January 2017 to December 2020 in Japan, focusing on ACS patients who underwent DCB or DES strategy for a single de novo lesion. One-year incidence of all-cause death, cardiovascular death, non-cardiovascular death, non-fatal ACS, stroke, and major bleeding events were compared. Subgroup analysis included lesion-based and ST-elevation myocardial infarction/non-ST-elevation ACS stratification. Results Among 5,212 propensity-matched ACS patients, DCB and DES strategies showed no significant differences in one-year incidence of all-cause death (4.5% vs. 4.6%, hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.72-1.19), cardiovascular death (2.5% vs. 2.5%, HR: 0.90, 95% CI: 0.64-1.26), non-cardiovascular death (2.0% vs. 2.1%, HR: 0.96, 95% CI: 0.65-1.42), and non-fatal ACS (1.7% vs. 2.0%, HR: 1.04, 95% CI: 0.70-1.54). DCB showed higher stroke occurrence (0.8% vs. 0.3%, HR: 2.33, 95% CI: 1.06-5.08) but lower major bleeding events (1.4% vs. 2.3%, HR: 0.65, 95% CI: 0.43-0.99) (Figure 1). Subgroup analyses did not reproduce these findings (Figure 2). Conclusions ACS patients using the DCB strategy demonstrated clinical outcomes equivalent to those undergoing the DES strategy at one year. Further investigation with an extended follow-up is necessary to confirm these findings.

Impact of cannabis abuse on the occurrence of stroke in young people: a systematic review and meta-analysis

BackgroundThe occurrence of stroke in young people has risen significantly. This can easily lead to physical disabilities, swallowing difficulties, and cognitive impairment, among other issues, having a profound impact on families and society. Risk factors for stroke in young people differ from those for traditional stroke, with cannabis abuse emerging as a significant high-risk factor. However, the extent of the impact of cannabis abuse on the occurrence of stroke and the rate of disability in young people remains unclear. To clarify this issue and provide evidence supporting the primary prevention of stroke in young people, this systematic review and meta-analysis summarizes the latest findings from previous studies.MethodsA systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted until April 2023. The review included observational studies comparing stroke risk estimates between cannabis abusers and non-users.ResultsThis review included six observational studies focusing on cannabis abuse, involving 119,284,152 participants. A significant association was found between cannabis abuse and an increased risk of stroke [OR = 1.14, 95% CI (1.08, 1.20)]. However, there was substantial heterogeneity among the studies (I2 = 89%, p < 0.001). After adjusting for confounders such as smoking and alcohol abuse, we found a stronger association between cannabis abuse and stroke in young adults [OR = 1.21, 95% CI (1.12, 1.29)]. Subgroup analyses revealed no significant difference in stroke risk between ischemic and hemorrhagic strokes (p = 0.43).ConclusionThe results of our systematic review and meta-analysis showed that cannabis abuse has a more significant effect on the occurrence of stroke in young people; however, it was not possible to distinguish whether cannabis abuse is more likely to cause ischemic or hemorrhagic stroke. Further research is needed to explore the impact of different drug types, dosages, and behaviors on stroke risk.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, Identifier CRD42023443261.

Association between tea consumption and stroke in the American adult females: analyses of NHANES 2011–2018 data

BackgroundEpidemiological surveys show that there is a significant gender difference in the incidence of stroke, with females having a noticeably higher rate than males. Accordingly, it is crucial to seek preventive measures for stroke specifically targeted at females. Although previous studies have shown that tea has been proven to be negatively correlated with stroke, the relationship between tea and stroke in American adult females is still unclear. Therefore, we aimed to investigate the relationship between tea consumption and the occurrence of stroke in American adult females.MethodsThe data analyzed is derived from the NHANES database between 2011 and 2018. The quantity of tea consumed was gathered from a 24-h dietary review. Stroke was identified by using questionnaire. The association between tea consumption and stroke was investigated using a weighted regression model. Then we used interaction testing and subgroup analysis to conduct a thorough analysis. Simultaneously, the association between the sugar content in tea and stroke was examined.ResultsThis study included 5731 adult females aged between 20 and 60 years. Compared to those who did not consume tea, the likelihood of stroke decreased by 9% for each additional 100 g of tea ingested by participants (OR = 0.91, 95%CI: 0.83–1.00). In the unadjusted model, those who drank 307.5–480 g of tea per day had a substantially decreased risk of stroke than those who did not drink tea (OR = 0.23, 95%CI: 0.08–0.64). After adjustment, this relationship also persisted (Model II: OR = 0.23, 95% CI: 0.08–0.64; Model III: OR = 0.23, 95% CI: 0.08–0.66). In both Model II and Model III, there was a statistically significant relationship between consuming 480–744 g of tea per day and the risk of stroke (Model II: OR = 0.39, 95%CI: 0.16–0.94; Model III: OR = 0.42, 95% CI: 0.18–0.98). Subgroup analysis revealed an interaction only with level of education (P = 0.031). Ultimately, we also demonstrated that people who drink sugar free tea have a lower risk of stroke, and even after adjusting for mixed factors.ConclusionThis study suggested that proper tea consumption was associated with a lower risk of stroke in adult females, which recommended drinking sugar free tea.

PI3K/AKT signaling and neuroprotection in ischemic stroke: molecular mechanisms and therapeutic perspectives.

It has been reported that the PI3K/AKT signaling pathway plays a key role In the pathogenesis of ischemic stroke. As a result, the development of drugs targeting the PI3K/AKT signaling pathway has attracted increasing attention from researchers. This article reviews the pathological mechanisms and advancements in research related to the signaling pathways in ischemic stroke, with a focus on the PI3K/AKT signaling pathway.The key findings include the following: (1) The complex pathological mechanisms of ischemic stroke can be categorized into five major types: excitatory amino acid toxicity, Ca2+ overload, inflammatory response, oxidative stress, and apoptosis. (2) The PI3K/AKT-mediated signaling pathway is closely associated with the occurrence and progression of ischemic stroke, which primarily involves the NF-kB, NRF2, BCL-2, mTOR, and endothelial NOS signaling pathways. (3) Natural products, including flavonoids, quinones, alkaloids, phenylpropanoids, phenols, terpenoids, and iridoids, show great potential as candidate substances for the development of innovative anti-stroke medications. (4) Recently, novel therapeutic techniques, such as electroacupuncture and mesenchymal stem cell therapy, have demonstrated the potential to improve stroke outcomes by activating the PI3K/AKT signaling pathway, providing new possibilities for the treatment and rehabilitation of patients with ischemic stroke. Future investigations should focus on the direct regulatory mechanisms of drugs targeting the PI3K/AKT signaling pathway and their clinical translation to develop innovative treatment strategies for ischemic stroke.

Synergies between diabetes and hyperhomocysteinaemia: New insights to predict and prevent adverse cardiovascular effects.

To explore the association of hyperhomocysteinaemia (HHcy) and diabetes synergies with cardiovascular events in the adult population of northern China. Data were collected from the Asymptomatic Polyvascular Abnomalities Community study for 2010 to 2019. Serum homocysteine (Hcy) levels were determined by enzyme-linked immunosorbent assay. The participants were categorized into four groups based on their Hcy levels and diabetes status: non-diabetes/non-HHcy, non-diabetes/HHcy, diabetes/non-HHcy and diabetes/HHcy. The composite endpoint consisted of the occurrence of first-ever stroke, myocardial infraction (MI) or all-cause mortality. Cox regression analyses were performed to evaluate the associations of diabetes and HHcy with cardiovascular disease (CVD) events. In total, 5278 participants were eligible (average age 55.1 years, 60% male). Over a follow-up of 9.1 years, 618 events were identified, 202 stroke, 52 MI and 406 all-cause deaths. Compared with the non-diabetes/non-HHcy group, hazard ratios with 95% confidence intervals in the diabetes/HHcy group for stroke, MI, major adverse cardiovascular event (MACE), all-cause death and composite endpoint were 1.85 (1.12-3.04), 1.33 (0.42-4.23), 1.78 (1.13-2.80), 2.24 (1.56-3.23) and 1.97 (1.47-2.65), respectively. Significant interactions between HHcy and diabetes status were found for stroke, MI and MACE (P for interaction = .002, .027 and .044, respectively). In addition, the association of diabetes/HHcy with stroke was modified by age (< 60 and ≥ 60 years; P for interaction = .016). The findings highlight the synergistic impact of diabetes and HHcy on CVD. Joint assessments of diabetes and Hcy levels should be emphasized for risk stratification and primary prevention of CVD.

Efficacy and Safety of Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke: A Systematic Review and Meta-analysis

Introduction: Stroke remains a major cause of morbidity and mortality after cardiac surgery. One factor associated with stroke occurrence is postoperative AF (pAF), which predisposes to the formation of atrial thrombus. As most thrombi form in the left atrial appendage (LAA), there is significant interest in LAA as a potential therapeutic target. While guidelines recommend direct oral anticoagulants (DOACs) as the preferred therapy for stroke prevention in patients with AF and a CHA2DS2-VASc score of ≥2, they cannot be administered to all patients who are poor candidates for long-term oral anticoagulation because of the high risk of bleeding, drug compliance and drug tolerance. There are limited data on the efficacy and safety of LAA occlusion (LAAO) during cardiac surgery for stroke prevention. Methods: A comprehensive and relevant search of randomised controlled trials, cohort and case–control studies was conducted. Outcome measures for ischaemic stroke events, all-cause mortality and pAF were extracted and analysed using a random-effects model. Results: Twelve studies were included and 18,982 subjects were analysed. There were 231 ischaemic stroke events in 9,473 patients who received LAAO compared with 371 ischaemic stroke events in 9,509 patients who did not receive LAAO. Concomitant LAAO showed a significant difference in ischaemic event rate (risk ratio [RR] 0.65; [95% CI: 0.55–0.77]; p&lt;0.00001, I2=0%) and all-cause mortality (RR 0.74; 95% CI [0.57–0.97]; p=0.03; I2=68%). For pAF, there was no difference between the two groups (RR 1.08; 95% CI [0.95–1.22]; p=0.24; I2=72). Conclusion: Concomitant LAAO was more effective in preventing ischaemic stroke events and all-cause mortality, with an overall moderate certainty of evidence. However, pAF rates were similar between LAAO and non-LAAO groups.