Optimal Stroke Prevention Research Articles

Cluster-specific risk factors for suboptimal thromboprophylaxis in contemporary European cohort of patients with atrial fibrillation: the EHRA-PATHS Project

Abstract Background Oral anticoagulation (OAC) is essential to optimal thromboprophylaxis in patients with atrial fibrillation (AF). Owing to bleeding risk concerns, OAC use may be challenging in clinically complex high-risk AF patients. Comorbidities might lead to suboptimal OAC use. We assessed cluster-specific risk factors for non-prescribing OAC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was constructed using data from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific risk factors for non-prescribing OAC were identified using univariate and multivariate logistic regression analyses. Results Of 18.799 patients, 2086 (11.1%) were not prescribed with OAC. Among the three clusters (see Table), OAC non-prescribing was significantly more prevalent in Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) or Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), both P<0.001, with no significant difference between Clusters 2 and 3 (P=0.161). Cluster-specific multivariable risk factors for non-prescribing OAC are shown in Table. In all three clusters AF clinical type was significantly associated with OAC non-use. In Cluster 1, OAC non-use was less likely in the presence of CHA2DS2-VASc stroke risk factors, while bleeding risk factors were predominant multivariable predictors of OAC non-use among elderly (Clusters 2 and 3). Conclusion Our findings in a large contemporary European cohort suggest that different considerations prevail in treatment decision on OAC use in AF patients in clinical practice, depending on patient’s age and AF clinical type, as well as the presence and type of underlying comorbidities. Our findings could help in formulating targeted interventions to optimize stroke prevention in different subgroups of AF patients.

Use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation across five stages of chronic kidney diseases

Abstract Background Although non-vitamin K antagonist oral anticoagulants (NOACs) were more and more commonly prescribed in the daily practice, data about the use of NOACs in atrial fibrillation (AF) patients with stage 4 and 5 chronic kidney diseases (CKD) are limited. In the present study, we compared the clinical outcomes of AF patients receiving NOACs and those receiving warfarin or non-OACs in different stages of CKD. Methods A total of 39217 AF patients aged >20 years whose data about creatinine clearance (CCr) were available were identified from the electronic health record database of a multi-center healthcare system in Taiwan. Patients were categorized into stage 1 to stage 5 CKDs, and the composite risks of ischemic stroke/systemic embolism, major bleeding and mortality were compared between non-OACs, warfarin and NOACs. Results Around 12.7% and 9.4% of study patients had a stage 4 and stage 5 CKD, respectively. Compared to non-OACs, the use of OACs (either warfarin or NOACs) were consistently associated with a lower risk of composite events from stage 1 to stage 4 CKD, but not for stage 5 CKD (warfarin: aHR 0.912, 95%CI 0.742-1.121; NOACs: aHR 0.993, 95%CI 0.653-1.537)(Figure 1). Compared to warfarin, NOACs were associated with a lower risk of adverse events for patients with stage 2 (aHR 0.630), stage 3 (aHR 0.712) and stage 4 CKD (aHR 0.749). However, the risk did not differ between warfarin and NOACs for stage 1 and stage 5 CKD (Figure 2). Conclusions Although data of the clinical trials for AF patients with stage 4 CKD were relatively lacking, NOACs should still be considered for this AF population. More data are necessary to guide optimal stroke prevention strategy for patients with stage 5 CKD.

Staged cerebral and brachiocephalic bypass in a patient with MCA and brachiocephalic steno-occlusion.

Background: Brachiocephalic steal is a rare phenomenon that may lead to hemodynamic abnormalities in the ipsilateral vertebral and carotid arteries. Current treatment includes management of vascular risk factors, endovascular stenting, and surgical management depending on the severity of symptoms. Case Information: We describe a patient with multiple vascular risk factors who presented with mild neurological symptoms and chronic right arm weakness associated with concurrent brachiocephalic steal and right MCA M1 stenosis on neuroimaging. Use of right superficial temporal artery to middle cerebral artery bypass and aorta-right subclavian bypass resulted in improved flow to the right hemisphere on quantitative magnetic resonance angiography and single-photon emission computed tomography, significantly lowering the risk of catastrophic ischemic stroke. Conclusion: Complex steal phenomena increase stroke risk. In cases of high-grade occlusion or advanced symptoms, endovascular or surgical management should be considered for optimal stroke prevention.

Cardiovascular Risk Factors and Disparities in Management of Embolic Stroke: A Western Sydney Perspective

Ischaemic stroke remains one of the leading causes of death and disability worldwide. The population of Western Sydney has a unique demographic with lower socioeconomic status and a culturally and linguistically diverse population. This study aims to investigate the demographics and cardiovascular risk factors of patients in Western Sydney, focusing on the prevalence and profile of cardioembolic (CE) strokes and embolic strokes of undetermined source (ESUS). Prospective data were collected in 463 patients with ischaemic stroke presenting to a tertiary centre in Western Sydney, who underwent predischarge transthoracic echocardiography. Patients with haemorrhagic strokes or unclear stroke diagnosis were excluded. Analysis of stroke subtype (CE, ESUS, or non-embolic) and clinical characteristics was performed based on age, gender, and prior atrial fibrillation (AF) prevalence. Of the 463 patients, 147 (32%) had CE strokes, and 147 (32%) had ESUS. Cardioembolic (CE) strokes were associated with older age (≥65 years) and a history of congestive cardiac failure. Older patients had higher rates of hypertension, ischaemic heart disease, AF, and congestive heart failure. History of AF was present in 67 patients (14.5%); however, only 51% received anticoagulation before admission despite a low bleeding risk. The transthoracic echocardiography characteristics of ESUS/non-embolic strokes differed from those of CE strokes; 20% of patients with ESUS had an enlarged left atrium, suggesting a subset of patients with ESUS with a left atrial myopathy. Patients with ischaemic stroke in Western Sydney have a high prevalence of cardiovascular risk factors which were often undertreated. Half of the patients with prior AF did not receive anticoagulation despite low bleeding risk, indicating a gap in optimal stroke prevention. There were distinct echocardiographic characteristics among stroke subtypes. Further analysis of left atrium parameters may provide greater insights into the pathogenesis and prevention of embolic strokes.

A non-linear connection between the total cholesterol to high-density lipoprotein cholesterol ratio and stroke risk: a retrospective cohort study from the China Health and Retirement Longitudinal Study

ObjectiveThe connection between total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) ratio and stroke risk is controversial. This study aims to examine the connection between the TC/HDL-C ratio and stroke in middle-aged and older individuals who are part of the China Health and Retirement Longitudinal Study (CHARLS).MethodsThis study conducted a retrospective cohort analysis, enrolling a total of 10,184 participants who met the designated criteria from CHARLS between 2011 and 2012. We then used the Cox proportional-hazards regression model to analyze the relationship between the TC/HDL-C ratio and stroke risk. Using a Cox proportional hazards regression model with cubic spline functions and smooth curve fitting, we were able to identify the non-linear relationship between the TC/HDL-C ratio and stroke occurrence. The sensitivity and subgroup analyses were also performed to investigate the connection between TC/HDL-C ratio and stroke.ResultsThis study revealed a statistically significant association between the TC/HDL-C ratio and stroke risk in subjects aged 45 years or older after adjusting for risk factors (HR: 1.05, 95%CI 1.00–1.10, P = 0.0410). Furthermore, a non-linear connection between the TC/HDL-C ratio and stroke risk was detected, with a TC/HDL-C ratio inflection point of 3.71. We identified a significant positive connection between the TC/HDL-C ratio and stroke risk, when the TC/HDL-C ratio was less than 3.71 (HR: 1.25, 95%CI 1.07–1.45, P = 0.0039). However, their connection was not significant when the TC/HDL-C ratio exceeded 3.71 (HR: 1.00, 95%CI 0.94–1.06, P = 0.9232). The sensitivity analysis and subgroup analyses revealed that our findings were well-robust.ConclusionOur study demonstrated a positive, non-linear connection between the TC/HDL-C ratio and stroke risk in middle-aged and older individuals. There was a significant positive connection between the TC/HDL-C ratio and stroke risk, when the TC/HDL-C ratio was less than 3.71. The current research can be used as a guideline to support clinician consultation and optimize stroke prevention measures for middle-aged and older adults.

Antiplatelet therapy in the prevention of recurrent ischemic stroke

Stroke that includes both ischemic and hemorrhagic events is a major cause of death worldwide. It is currently the most common cause of disability. The risk of recurrence is the highest among cases where a recent stroke or transient ischemic attack was left untreated. In about 30% of these cases, a recurrent stroke leads to the worsening neurological symptoms or even death. Therefore, primary prevention of first stroke and secondary prevention of recurrent stroke are a top priority. Primary prevention of ischemic stroke includes lifestyle modification and diets, treatment of risk factors including hypertension, diabetes mellitus and lipid disorders, antiplatelet therapy for high vascular risk patients, and anticoagulation therapy in atrial fibrillation. Secondary prevention of ischemic stroke includes additional carotid surgery in symptomatic patients. Up to 90% of all strokes are preventable, and attributable to major modifiable risk factors. Optimal stroke prevention requires a harmonious, integrated approach to educating about stroke risk and healthy lifestyle, simple screening and management of patients for a history and presence of modifiable and treatable causal risk factors, and improving social and environmental factors. Intake of antiplatelet agents according to the subtype improves the prognosis of patients after an ischemic stroke or transient ischemic attack. Current data on stroke recurrence and mortality are important to examine trends, risk factors, and treatment effects.

Giant Aneurysm of the Interatrial Septum: A Multidisciplinary Approach

A 46-year-old woman presented for a routine echocardiogram, which revealed a giant atrial septal aneurysm (ASA) with an atrial septal defect (ASD). We surgically excised the ASA and closed the ASD with a pericardial patch. ASA, although rare, poses embolic risks, thus necessitating closure when associated with shunts. Optimal stroke prevention remains uncertain.

A Recurring neurorenal affair; Post CKD stroke

Madam, The inability to speak, see, and move, medically known as aphasia, visual loss, and limb paralysis respectively, are well-known manifestations caused by inadequate blood supply or oxygen to the brain, leading to a condition known as Stroke. It is a major global health concern, and Pakistan is estimated to have 250 cases of Stroke annually per 100,000 population[1].Multiple known risk factors such as hypertension, diabetes, old age, myocardial infarction and chronic kidney disease contribute (CKD) to such high incidence. CKD is defined as kidney impairment or less than 60 mL/min/1.73 m (2) of glomerular filtration rate (GFR) for three months or longer. In 2021, CKD was established as an independent risk factor for stroke by Melaine and colleagues. [2] Further supporting the link between Stroke and CKD, a new recent study by Ueki et al. published in STROKE shows that the functional dysfunction of the kidney (eGFR) and the kidney damage (proteinuria) caused by CKD are associated both independently and synergistically with increased risk of not one-time but recurrent strokes. Out of 12576 enrolled stroke patients, 20% (2481 patients) who developed CKD suffered from recurrent Strokes. [3]. This raises significant concern, particularly in Pakistan, where there is only 1 neurologist per 1 million population [1] The decreased number of specialists is not the only reason why this study raises a cause of concern. With only 10 Stroke care units and just 6 out of them offering intravenous thrombectomy, managing Stroke is already a challenge. Pakistan unfortunately, also suffers from decreased availability of alteplase, an expensive drug required for timely management of Stroke leaving mechanical thrombectomy as the possible treatment option, which is again only offered at hospitals.[1] But what can be done to tackle this impending burden? The answer is prevention. In addition to the evident solution of increasing the number of stroke care facilities and improving the availability of alteplase, Transcranial Dopplers (TCD) can be utilized as a non-invasive screening test to monitor brain health in CKD patients [4]. People need to be made more educated on taking better control over their health by being compliant with medications if suffering from hypertension or diabetes, the two major risk factors of CKD. An integrative strategy should be employed, bringing nephrologists, neurologists, and patients together at one table to discuss the next steps and optimize stroke prevention and management.

Identification of atrial fibrillation phenotypes at low risk of stroke in patients with CHA2DS2-VASc ≥2: Insight from the China-AF study.

Patients with atrial fibrillation (AF) are highly heterogeneous, and current risk stratification scores are only modestly good at predicting an individual's stroke risk. We aim to identify distinct AF clinical phenotypes with cluster analysis to optimize stroke prevention practices. From the prospective Chinese Atrial Fibrillation Registry cohort study, we included 4337 AF patients with CHA2 DS2 -VASc≥2 for males and 3 for females who were not treated with oral anticoagulation. We randomly split the patients into derivation and validation sets by a ratio of 7:3. In the derivation set, we used outcome-driven patient clustering with metric learning to group patients into clusters with different risk levels of ischemic stroke and systemic embolism, and identify clusters of patients with low risks. Then we tested the results in the validation set, using the clustering rules generated from the derivation set. Finally, the survival decision tree was applied as a sensitivity analysis to confirm the results. Up to the follow-up of 1 year, 140 thromboembolic events (ischemic stroke or systemic embolism) occurred. After supervised metric learning from six variables involved in CHA2 DS2 -VASc scheme, we identified a cluster of patients (255/3035, 8.4%) at an annual thromboembolism risk of 0.8% in the derivation set. None of the patients in the low-risk cluster had prior thromboembolism, heart failure, diabetes, or age older than 70 years. After applying the regularities from metric learning on the validation set, we also identified a cluster of patients (137/1302, 10.5%) with an incident thromboembolism rate of 0.7%. Sensitivity analysis based on the survival decision tree approach selected a subgroup of patients with the same phenotypes as the metric-learning algorithm. Cluster analysis identified a distinct clinical phenotype at low risk of stroke among high-risk [CHA2 DS2 -VASc≥2 (3 for females)] patients with AF. The use of the novel analytic approach has the potential to prevent a subset of AF patients from unnecessary anticoagulation and avoid the associated risk of major bleeding.

External validations of the ABCD2 score in prediction of stroke risk after transient ischemic attack. A Tunisian hospital-based cohort study

Background and purpose Identification of patients with high risk of stroke after transient ischemic attack (TIA) could be helpful to optimize stroke prevention. We aimed to externally validate the ABCD2 score for the prediction of stroke after TIA in a Tunisian population. Methods We conducted a retrospective observational study of consecutive patients admitted for TIA in four university hospitals in Tunisia. Patients were screened for onset of stroke. Sensitivity, specificity, positive and negative predictive values with areas under the receiver operating characteristic (ROC) curves were calculated for risk of stroke at 2, 7, 30 and 90 days after the index event. Results Of 415 patients screened in this study, the total cumulative subsequent stroke rates after TIA at 2, 7, 30 and 90 days were respectively, 4.8%, 10.6%, 13.5% and 20.2%. Using a cut-off value of 4, the ABCD2 showed an overall good sensitivity (95%, 97.7%, 96.4% and 97.6% respectively at 2, 7, 30 and 90 days). Areas under ROC cure of the ABCD2 score in patients with TIA for stroke onset at 2, 7, 30 and 90 days were respectively 0.67 (95% CI, 0.55-0.79), 0.79 (95% CI, 0.71-0.85), 0.79 (95% CI, 0.72-0.85), and 0.76 (95% CI, 0.70-0.81). Conclusion Our findings suggest that the ABCD2 score could be used in our population to discriminate patient with TIA at low and high risk of developing recurrent stroke.

Incidence of Stroke in the Aboriginal and Non-Aboriginal Populations of Australia: A Data Linkage Study.

Most estimates of stroke incidence among Aboriginal and Torres Strait Islander (hereinafter Aboriginal) Australians are confined to single regions and include small sample sizes. We aimed to measure and compare stroke incidence in Aboriginal and non-Aboriginal residents across central and western Australia. Whole-population multijurisdictional person-linked data from hospital and death datasets were used to identify stroke admissions and stroke-related deaths (2001-2015) in Western Australia, South Australia, and the Northern Territory. Fatal (including out-of-hospital deaths) and nonfatal incident (first-ever) strokes in patients aged 20-84 years were identified during the 4-year study period (2012-2015), using a 10-year lookback period to exclude people with prior stroke. Incidence rates per 100 000 population/year were estimated for Aboriginal and non-Aboriginal populations, age-standardized to the World Health Organization World Standard population. In a population of 3 223 711 people (3.7% Aboriginal), 11 740 incident (first-ever) strokes (20.6% regional/remote location of residence; 15.6% fatal) were identified from 2012 to 2015, 675 (5.7%) in Aboriginal people (73.6% regional/remote; 17.0% fatal). Median age of Aboriginal cases (54.5 years; 50.1% female) was 16 years younger than non-Aboriginal cases (70.3 years; 44.1% female; P<0.001), with significantly greater prevalence of comorbidities. Age-standardized stroke incidence in Aboriginal people (192/100 000 [95% CI, 177-208]) was 2.9-fold greater than in non-Aboriginal people (66/100 000 [95% CI, 65-68]) aged 20-84 years; fatal incidence was 4.2-fold greater (38/100 000 [95% CI, 31-46] versus 9/100 000 [95% CI, 9-10]). Disparities were particularly apparent at younger ages (20-54 years), where age-standardized stroke incidence was 4.3-fold greater in Aboriginal people (90/100 000 [95% CI, 81-100]) than non-Aboriginal people (21/100 000 [95% CI, 20-22]). Stroke occurred more commonly, and at younger ages, in Aboriginal than non-Aboriginal populations. Greater prevalence of baseline comorbidities was present in the younger Aboriginal population. Improved primary prevention is required. To optimize stroke prevention, interventions should include culturally appropriate community-based health promotion and integrated support for nonmetropolitan health services.

Are Ischemic Strokes the Same? The Special Case Argument of Atrial Fibrillation

A comprehensive evaluation is necessary to identify the etiologic factors in order to select optimal stroke-prevention measures. Atrial fibrillation is one of the most important stroke causes. Although anticoagulant therapy is the treatment of choice for patients with nonvalvular atrial fibrillation, it should not be considered uniformly to treat all patients given the high mortality associated with anticoagulant-related hemorrhages. The authors propose a risk-stratified individualized approach for stroke prevention in patients with nonvalvular atrial fibrillation by considering nonpharmacologic approaches for patients at high hemorrhage risk or otherwise unsuitable for lifelong anticoagulation.

Opportunistic screening for atrial fibrillation using a photoplethysmography technique in geriatric patients, a preliminary analysis of the Dutch-GERAF Study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Happitech. Provided the mobile photoplethysmography application Background Undiagnosed atrial fibrillation (AF) poses a great risk for stroke in high-risk patients. Different screening strategies have been developed to identify these patients. Geriatric patients often have multimorbidity, and are to be considered a population at very high risk for development of AF and cardiovascular events, but may have less access to wearable screening devices. Purpose The Dutch multicentre study into opportunistically screening of Geriatric patients for Atrial Fibrillation using a PPG smartphone App (the Dutch-GERAF Study) applies opportunistic screening to ambulatory geriatric patients, to identify new cases of AF and optimize stroke prevention. This preliminary analysis describes the feasibility and willingness to use of a smart phone photoplethysmography (PPG) application in an ambulatory cohort. Method Analysis of participation data and PPG use, of all included patients aged 70 years or older within the GERAF study. The GERAF study is a multicentre study on opportunistic screening for AF using a PPG application among patients visiting a geriatric outpatient clinic. All patients without a pacemaker/ICD, severe tremor, or severe dementia were invited to participate, during a 6 months screening period. Patients were stimulated to use the application at home on their own mobile device at least 3 times within 6 months following inclusion. If preferred by the patient, the application was installed on the mobile device of a spouse or other family member. The PPG signals were analysed using the commercially available algorithm. Results Data on PPG use for patients was available for 568 patients. Of these, 122 (21.5%) had a history of AF, and therefore not included in this analysis. Data on PPG use was analysed of 446 patients, 240 were female (54%), average age was 79 ± 5.5 years, the oldest patient was 95 years old. In total, patients performed 2232 PPG recordings within 6 months, in which a sufficient signal was acquired in 1874 (84%) recordings. The signal appeared sufficient at the first attempt in 79.3% of the recordings. In case of a failed first attempt, 60.5% of the patients immediately performed at least one extra recording until sufficient signal quality was achieved, and overall 61.2% of the patients performed at least 2 PPG recordings. Only 69 (15.5%) patients who consented to participation, did not perform any recordings. Conclusion This analysis of preliminary GERAF PPG data shows that very old subjects (with a mean age of almost 80 years) are willing and able to use eHealth applications on a mobile device. Most PPG recordings were of sufficient signal quality, and more than half of the patients were willing to perform repeated recordings.

PO-02-134 REAL WORLD CLINICAL MANAGEMENT AFTER SURGICAL LEFT ATRIAL APPENDAGE EXCISION

Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Optimal stroke prevention management after surgical LAA management with respect to imaging and continuation of oral anticoagulation (OAC) is not well understood. To elucidate real world clinical management of patients undergoing surgical LAA management. Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Clinical follow-up, including transesophageal echocardiography (TEE) data and OAC use were catalogued via chart review. Success of LAA ligation was defined as maximal stump depth < 1.0 cm (with no distal leak) in all dimensions imaged. Of the 458 participants, 115 (25%) had a post-operative TEE (with average post-operative time of 36 weeks). Of these 115 patients, 95 were discharged from cardiac surgery on OAC and 83/115 (72%) had successful LAA closure by TEE criteria; 19/115 had inadequate closure and 13/115 did not have sufficient image quality to assess LAA closure. Among the 83 patients with TEE-verified successful LAA closure, 7 had stroke during follow-up; of these strokes 3/7 occurred within 4 weeks of cardiac surgery. Only 1/7 patients was not on OAC at the time of their stroke. (Table 1) Among the 83 patients with successful LAA closure, 70 had been discharged on OAC following cardiac surgery. Of these 47/70 subsequently had their OAC discontinued; 43/47 of those discontinuations occurred after the TEE. Most patients undergoing surgical LAA management do not receive follow-up TEE imaging. When TEE is performed, surgical excision of the LAA is shown to have a moderate success rate. Clinical management after surgical LAA management, with regard to LAA imaging and OAC continuation, is highly heterogeneous.

A Novel Mechanism of the “Three Territory Sign” in Acute Ischemic Stroke (P14-5.014)

<h3>Objective:</h3> To present an atypical mechanism for multi-territorial infarction, the “Three Territory Sign” (TTS), in patients with Acute Ischemic Stroke and malignancy. <h3>Background:</h3> Multi-focal ischemic infarcts are often associated with cardioembolism. However, bilateral anterior circulation and posterior circulation infarcts are known as the TTS which is most commonly associated with hypercoagulable state due to malignancy Two commonly recognized mechanisms for the TTS in this setting are localized DIC and embolization of vegetations from non-bacterial thrombotic endocarditis. We present a third possible mechanism for the TTS. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 67-year-old woman with history of Stage IV metastatic melanoma presented to the emergency department with one-day history of fine motor dysmetria and weakness of the right hand. Brain MRI revealed extensive scattered infarcts throughout the bilateral anterior and posterior circulation. A routine stroke work-up including vessel imaging, lipid panel, A1C, TTE and TEE were unrevealing. Due to persistent eosinophilia, she then underwent cardiac MRI to assess for possible chemotherapy-induced eosinophilic myocarditis. While this was not present, her cardiac MRI revealed a left-ventricular intramural metastasis with necrotic core directly invading the ventricular surface. No other cardiac sources were discovered and the most likely source of this patient’s embolic strokes was felt to be thrombosis superimposed upon the necrotic intraventricular tumor. <h3>Conclusions:</h3> Intraventricular cardiac metastasis is an uncommon mechanism of malignancy-associated TTS. Physicians should consider evaluation for cardiac metastases in patients with TTS if it will change optimal secondary stroke prevention or cancer treatment. <b>Disclosure:</b> Dr. Figueroa has nothing to disclose. Dr. Kazmirczak has nothing to disclose. Dr. Ramezani Hashtjin has nothing to disclose. Dr. Streib has nothing to disclose.

Comparative Effectiveness and Safety of Oral Anticoagulants by Dementia Status in Older Patients With Atrial Fibrillation

The development of an optimal stroke prevention strategy, including the use of oral anticoagulant (OAC) therapy, is particularly important for patients with atrial fibrillation (AF) who are living with dementia, a condition that increases the risk of adverse outcomes. However, data on the role of dementia in the safety and effectiveness of OACs are limited. To assess the comparative safety and effectiveness of specific OACs by dementia status among older patients with AF. This retrospective comparative effectiveness study used 1:1 propensity score matching among 1 160 462 patients 65 years or older with AF. Data were obtained from the Optum Clinformatics Data Mart (January 1, 2013, to June 30, 2021), IBM MarketScan Research Database (January 1, 2013, to December 31, 2020), and Medicare claims databases maintained by the Centers for Medicare & Medicaid Services (inpatient, outpatient, and pharmacy; January 1, 2013, to December 31, 2017). Data analysis was performed from September 1, 2021, to May 24, 2022. Apixaban, dabigatran, rivaroxaban, or warfarin. Composite end point of ischemic stroke or major bleeding events over the 6-month period after OAC initiation, pooled across databases using random-effects meta-analyses. Among 1 160 462 patients with AF, the mean (SD) age was 77.4 (7.2) years; 50.2% were male, 80.5% were White, and 7.9% had dementia. Three comparative new-user cohorts were established: warfarin vs apixaban (501 990 patients; mean [SD] age, 78.1 [7.4] years; 50.2% female), dabigatran vs apixaban (126 718 patients; mean [SD] age, 76.5 [7.1] years; 52.0% male), and rivaroxaban vs apixaban (531 754 patients; mean [SD] age, 76.9 [7.2] years; 50.2% male). Among patients with dementia, compared with apixaban users, a higher rate of the composite end point was observed in warfarin users (95.7 events per 1000 person-years [PYs] vs 64.2 events per 1000 PYs; adjusted hazard ratio [aHR], 1.5; 95% CI, 1.3-1.7), dabigatran users (84.5 events per 1000 PYs vs 54.9 events per 1000 PYs; aHR, 1.5; 95% CI, 1.2-2.0), and rivaroxaban users (87.4 events per 1000 PYs vs 68.5 events per 1000 PYs; aHR, 1.3; 95% CI, 1.1-1.5). In all 3 comparisons, the magnitude of the benefits associated with apixaban was similar regardless of dementia diagnosis on the HR scale but differed substantially on the rate difference (RD) scale. The adjusted RD of the composite outcome per 1000 PYs for warfarin vs apixaban users was 29.8 (95% CI, 18.4-41.1) events in patients with dementia vs 16.0 (95% CI, 13.6-18.4) events in patients without dementia. The corresponding adjusted RD estimates of the composite outcome were 29.6 (95% CI, 11.6-47.6) events per 1000 PYs in patients with dementia vs 5.8 (95% CI, 1.1-10.4) events per 1000 PYs in patients without dementia for dabigatran vs apixaban users and 20.5 (95% CI, 9.9-31.1) events per 1000 PYs in patients with dementia vs 15.9 (95% CI, 11.4-20.3) events per 1000 PYs in patients without dementia for rivaroxaban vs apixaban users. The pattern was more distinct for major bleeding than for ischemic stroke. In this comparative effectiveness study, apixaban was associated with lower rates of major bleeding and ischemic stroke compared with other OACs. The increased absolute risks associated with other OACs compared with apixaban were greater among patients with dementia than those without dementia, particularly for major bleeding. These findings support the use of apixaban for anticoagulation therapy in patients living with dementia who have AF.

Abstract 160: Etiologies Of Intracerebral Hemorrhage In Patients With Atrial Fibrillation On Or Off Oral Anticoagulants: The Neuro-Afib Study

Background: Intracerebral hemorrhage (ICH) is the most feared complication of oral anticoagulants (OAC) used to prevent ischemic strokes (IS) in patients with atrial fibrillation (AF). As different ICH etiologic factors correspond to different ICH risks, we aimed to present the causes of ICH in AF patients who were or were not using OAC, based on data from a multicenter contemporary cohort. Methods: The Neuro-AFib study is a multicenter effort to elucidate the current causes and consequences of IS and ICH in AF patients. Detailed clinical, laboratory and multimodal imaging data were collected from consecutive patients with AF admitted to 15 US stroke centers with an IS or ICH between 1/2018-12/2019. Etiologic factors of AF patients who were admitted with ICH on OAC (OAC-ICH) and off OAC (nonOAC-ICH) will be compared. Results: A total of 868 patients presented with ICH and had a diagnosis of AF, either previously known (88%) or diagnosed during admission (12%). 571 patients (66%) were on OAC at the time of their ICH of whom 58% were on direct OAC (DOAC), 40% on warfarin and 2% on heparin. OAC-ICH patients were older than nonOAC-ICH (76.6±10 vs 74.4±13, p=0.006) while sex distribution was the same in both groups (43% female). CHA 2 DS 2 -VASC was higher in OAC-ICH (4.3±1.6 vs 3.9±1.9, p=0.001) but HAS-BLED score was the same in both groups (2.7±1.1). Cerebral amyloid angiopathy (CAA) was diagnosed in 42.5% of the ICH patients based on modified Boston criteria while hypertensive cerebral small vessel disease (HTN-cSVD) in 57.5%. HTN-cSVD was the more common ICH etiology among OAC-ICH (65%) compared to nonOAC-ICH (49%). Among OAC-ICHs, DOAC-related ICHs tended to be more commonly of hypertensive etiology when compared to warfarin-ICH (p=0.09). Conclusions: Our study is the first to report the etiologic mechanisms of ICH in AF patients on or off OAC. CAA is known to be a major cause of OAC-ICH with exceedingly high recurrence rates. Despite this fact, HTN-cSVD was more common among OAC-ICH (especially DOAC-ICH) patients, supporting the view that the presence/absence of HTN-cSVD risk markers such as deep microbleeds are as important as CAA-markers in determining the optimal stroke prevention method in AF patients (left atrial appendage closure vs lifelong OAC).

Abstract HUP13: Assessing Patient Perceptions Of Strokes Reveals Limited Coherence And Perceived Barriers To Treatment Compliance In Hospitalized Stroke Patients Independent Of Race/ethnic And Socioeconomic Factors

Introduction: A large factor contributing to stroke prevention is medication adherence and lifestyle adjustments. Patients' attitudes and perceptions towards health may contribute to a patient's likelihood of optimal stroke prevention. Methods: We surveyed hospitalized stroke patients and their caregivers using the Cerebrovascular Attitudes and Beliefs Scale-Revised and the Illness Perception Questionnaire-Revised survey before hospital discharge. Parametric and nonparametric tests were used to assess statistical significance, and Cronbach's was used for inter-rater variance using SPSS Statistics 27. Results: Our study included 39 patients &amp; 6 caregivers, median age 66 (interquartile range 56-78), 60% woman, 69% Non-Hispanic White, 71% ischemic, 58% non-LVO, 4% tPA, 67% Medicare, 36% rural, and the median time since stroke onset was 3-5 days. Cronbach's alphas indicated that all sub-scales were reliable with a high level of internal consistency (α=0.829). More patients identified as having difficulty understanding their medical condition smoked (p=0.024), did not have atrial fibrillation (p=0.009), and did not have hyperlipidemia (p=0.036). Also, patients with diabetes were more likely to perceive obstacles to treatment compliance (p=0.039), prolonged recovery (p=0.042), and more severe consequences (p=0.046). Patients who had experienced a non-LVO were more likely to perceive the ineffectiveness of their treatments (p=0.034). More patients who had experienced a TIA perceived barriers to treatment compliance (p=0.049). Though there were no readmissions within 30 days and only one fatality related to GI bleed, of the 38% of patients that did not keep their post-hospital discharge follow-up neurology appointment, more had difficulty understanding their medical condition (p=0.036). There was no association with race, gender, insurance, rural vs. urban, or ethnicity. Conclusions: Interestingly, our findings identified modifiable stroke risk factors. We also saw a link between health care perceptions and no-show neurology clinic visits post-stroke hospitalization. Effective personalized patient education before hospital discharge is needed to help improve secondary stroke prevention management.

Abstract 33: Risk Scores And Brain Mri Markers In Distinguishing Ischemic Stroke And Intracerebral Hemorrhage Risk Among Atrial Fibrillation Patients: The Neuro-Afib Study

Background: Recent studies cast doubt on the accuracy of the most-commonly used risk scores (CHA 2 DS 2 -VASC and HAS-BLED) in differentiating the risk of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) among patients with fibrillation (AF). Because of the importance of AIS/ICH risk determination for choice of proper preventive approaches, we aimed to compare the value of these risk scores and brain MRI markers to differentiate the occurrence of AIS and ICH in a large cohort of AF-related strokes. Methods: The Neuro-AFib study is a multicenter effort to elucidate the causes and consequences of AIS and ICH in AF patients. Demographics, CHA 2 DS 2 -VASC and HAS-BLED scores, and ischemic/hemorrhagic brain MRI markers were compared between AF patients admitted with AIS and ICH to 15 academic stroke centers in the US between 1/2018-12/2019. Results: Of 5694 stroke admissions with AF, 4826 (84.8%) had AIS and 868 (15.2%) ICH. Mean age was similar between groups (75.9±11.5 vs 76.6±11.9, p=0.1), more ICH patients were male (57% vs 50%). Pre-index event CHA 2 DS 2 -VASC (4.14±1.6 vs 4.22±1.6) and HAS-BLED (2.71±1.09 vs 2.68±1.13) were similar between groups [both p&gt;0.2]. Cerebral microbleeds (CMB, 56% vs 33.5%), cortical superficial siderosis (cSS, 15% vs 9.4%), and moderate-to-severe leukoaraiosis (41% vs 33.4%) were more commonly found among ICH patients compared to AIS (all p&lt;0.001). Chronic lacunar infarcts (43.5% vs 39.5%, p=0.03) and chronic non-lacunar infarcts (29% vs 18%, p&lt;0.001) were more commonly found in AIS. In a multivariable logistic regression model that included all variables above, male sex, presence of CMBs, cSS, moderate-to-severe leukoaraiosis were associated with ICH, chronic non-lacunar infarcts with AIS (all p&lt;0.005), while CHA 2 DS 2 -VASC (p=0.9) and HAS-BLED (p=0.9) were not related to the stroke type. Conclusions: Data from our multicenter study confirm the lack of specificity of CHA 2 DS 2 -VASC and HAS-BLED to categorize the risk of AIS vs ICH in AF patients. The chronic MRI findings (CMB, cSS, moderate-to-severe leukoaraiosis, chronic infarcts) should be incorporated into risk scores, and their predictive value for AIS and ICH should be investigated in prospective studies to select optimal stroke prevention methods in AF patients.

August 2022 Stroke Highlights

August 2022 Stroke Highlights