Overall Incidence Of Stroke Research Articles

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis

Background & objectivesBlunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. MethodsWe searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. ResultsWe included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). ConclusionLocal anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

Incidence and risk factors for stroke after hip fracture: a meta-analysis

Hip fractures represent a high burden and are associated with mortality in up to 30% of the cases. Stroke complications can be devastating and increase mortality and disability in elderly patients. This study aimed to determine the overall incidence and risk factors for stroke in patients with hip fractures. A systematic search of the literature using PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases was carried out. Studies have reported the incidence of stroke in patients > 50 years of age with hip fractures. Data were extracted according to PRISMA guidelines (PROSPERO: CRD42023384742). Data were combined using Review Manager version 5.4. A random-effects model was adopted if a significant heterogeneity was observed. The primary outcome was the incidence of stroke in patients with hip fractures. The secondary outcomes of interest included the influence on the incidence of demographic factors, associated conditions, habits, and analytical parameters. Of the 635 initially retrieved studies, 18 were included, with 256,197 patients. The mean age of the patients ranged from 55 to 84 years old. The overall incidence of stroke in patients with hip fracture was 6.72% (95% CI 4.37–9.07%. The incidence of stroke by region was highest in the American continent (8.09%, 95% CI 3.60–12.58%; P > 0.001). Regarding associated conditions diabetes significantly increased the risk of stroke (OR 1.80, 95% CI 1.41–2.30). Respect to patient characteristics, BMI greater than 24.4 and female gender did not significantly increase the risk of stroke: (OR 1.07, 95% CI 0.74–1.56) and (OR 1.15, 95% CI 0.91–1.46). Lastly, lower albumin concentrations were a risk factor for stroke in patients with hip fracture (MD − 3.18, 95% CI − 4.06 to 2.31). In conclusion, the incidence of stroke after hip fracture was 6.72%. The incidence of stroke increases over time, and the closely associated risk factors are diabetes and low albumin level.

Incidence and outcomes for stroke in Ulaanbaatar, Mongolia, during 2019–21: a prospective population-based study

In the absence of reliable data to quantify the burden of stroke, we aimed to determine the incidence and outcome of stroke through the conduct of a prospective population-based study in Ulaanbaatar, Mongolia, during 2019-21. All cases of stroke were identified through surveillance of multiple overlapping sources of hospitalised, ambulatory, and deceased individuals, using standardised diagnostic criteria in adult (aged ≥16 years) residents of the six urban districts of Ulaanbaatar, Mongolia (population person-years, N=1 896 965) between Jan 1, 2019, and Dec 31, 2020. Data on sociodemography, medical history, and management were collected. Crude and standardised incidence were calculated for first-ever stroke and its major pathological subtypes, and reported with 95% CIs. Outcomes were 28-day case fatality ratios and functional recovery on the modified Rankin scale at 90 days and 1 year. 3803 strokes in 3738 patients were identified, of which 2962 were first-ever incident cases (mean age 59 years [SD 13], 1161 [39·2%] females). Annual incidence of first-ever stroke (per 100 000) was 156·1 (95% CI 150·5-161·8) on a crude basis, 171·6 (157·5-185·6) when age-adjusted to the Mongolian population, and 140·3 (136·7-143·9) when age-adjusted to the world population. World-adjusted incidence of pathological subtypes were 66·6 (95% CI 64·8-68·3) for ischaemic stroke, 54·5 (53·0-56·1) for intracerebral haemorrhage, and 18·7 (18·3-19·1) for subarachnoid haemorrhage. Men were twice as likely to suffer ischaemic stroke and intracerebral haemorrhage as women, but the risks were similar for subarachnoid haemorrhage; these patterns were consistent across age-groups. The predominant risk factors were hypertension seen in 1363 (63·1%) of 2161, smoking in 596 (26·8%) of 2220, regular alcohol consumption in 533 (24·0%) of 2220, obesity in 342 (16·1%) of 2125, and diabetes in 282 (12·7%) of 2220. There was little use (0·9%) of thrombolysis for acute ischaemic stroke, partly due to delays in presentation after the onset of symptoms (median 16·0 h [IQR 3·0-48·0]). The 28-day case-fatality rate was 36·1% (95% CI 34·3-37·9) overall, and 14·8% (12·8-16·7) for ischaemic stroke, 52·9% (49·9-55·8) for intracerebral haemorrhage, and 54·3% (49·4-59·1) for subarachnoid haemorrhage. Corresponding figures for poor functional outcome at 1-year, defined by scores of 3-6 for death or dependency on the mRS, were 61·6% (95% CI 59·8-63·4), 47·5% (44·7-50·3), 77·0% (74·5-79·5), and 61·8% (57·0-66·5), respectively. The urban population of Ulaanbaatar, Mongolia, has a high incidence of stroke, particularly for intracerebral haemorrhage and subarachnoid haemorrhage, from which half of patients die within 1 month and more than two-thirds are either dead or dependent at 90 days. Although the overall incidence of stroke is similar to other countries, it occurs at a mean age of 60 years, which is at least 10 years younger than in high-income countries. These epidemiological data can inform the implementation of future programmes and scale-up activities for the primary and secondary prevention of stroke, and in the organisation of systems of care. Science and Technology Foundation of the Ministry of Education, Culture, and Science of Mongolia and The George Institute for Global Health.

Brain Stress Test for Assessing Risk for Hemodynamic Stroke.

In patients with intracranial steno-occlusive disease (SOD), the risk of hemodynamic stroke depends on the poststenotic vasodilatory reserve. Cerebrovascular reactivity (CVR) is a test for vasodilatory reserve. We tested for vasodilatory reserve by using PETCO2 as the stressor, and Blood Oxygen Level Dependent (BOLD) MRI as a surrogate of blood flow. We correlate the CVR to the incidence of stroke after a 1-year follow-up in patients with symptomatic intracranial SOD. In this retrospective study, 100 consecutive patients with symptomatic intracranial SOD that had undergone CVR testing were identified. CVR was measured as % BOLD MR signal intensity/mmHg PETCO2. All patients with normal CVR were treated with optimal medical therapy; those with abnormal CVR were offered revascularization where feasible. We determined the incidence of stroke at 1 year. 83 patients were included in the study. CVR was normal in 14 patients and impaired in 69 patients ipsilateral to the lesion. Of these, 53 underwent surgical revascularization. CVR and symptoms improved in 86% of the latter. The overall incidence of stroke was 4.8 % (4/83). All strokes occurred in patients with impaired CVR (4/69; 2/53 in the surgical group, all in the nonrevascularized hemisphere), and none in patients with normal CVR (0/14). Our study confirms that CO2-BOLD MRI CVR can be used as a brain stress test for the assessment of cerebrovascular reserve. Impaired CVR is associated with a higher incidence of stroke and normal CVR despite significant stenosis is associated with a low risk for stroke.

Successful Thrombolysis of an Ischemic Stroke Immediately following Transurethral Resection of Prostate in an Elderly Male

Abstract The overall incidence of stroke in the perioperative period following noncardiac, nonneurologic, and noncarotid surgery has been reported to be between 0.1% and 0.8%. Thrombolysis in the postoperative stroke is controversial, with a possible high risk of surgical site hemorrhage (SSH) and intracerebral hemorrhage. We report a case of an old male who developed an ischemic stroke on postoperative day 0 of transurethral resection of prostate. He was thrombolysed with tenecteplase but developed minor SSH as well as cerebral hemorrhagic transformation (HI2). Both complications were managed with appropriate measures. The patient recovered completely (NIHSS 0) and was discharged 1 week later. To the best of our knowledge, this is the first report of a successful thrombolysis in a patient developing acute ischemic stroke following a major urologic surgery on the day of surgery.

Incidence of Stroke in Randomized Trials of COVID-19 Therapeutics: A Systematic Review and Meta-Analysis.

COVID-19 has been frequently associated with an increased risk of thrombotic complications. There have also been reports of an increased likelihood of stroke, although its true incidence in patients with COVID-19 is currently unknown. Electronic databases PubMed and Scopus were searched from inception up to July 30, 2021 to identify randomized controlled studies in patients with confirmed COVID-19 undergoing one or more interventions. Studies were screened for eligibility using a predefined inclusion criterion and selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random-effects model meta-analysis was conducted, and heterogeneity was assessed using I-squared test. Out of 3960 potentially eligible articles, 77 randomized studies (38 732 patients) were included. Mean age of the study population was 55±9.3 years. Females constituted 38% of the study population and mean duration of follow-up after study enrollment was 23±12.9 days. Cumulative incidence of stroke in the overall study population was 0.001 (95% CI, 0.001-0.002) with a total of 65 events in 38 732 patients, corresponding to an absolute incidence of 0.168%. Incidence of stroke in the inpatient population was 0.001 (95% CI, 0.001-0.002; 65 events in 37 069 patients), corresponding to an absolute incidence of 0.175%. No strokes were observed in the outpatient setting. The overall incidence of stroke in patients with COVID-19 appears to be lower than that reported in previous observational reports.

Impact of Individual Income Level on Late Mortality After Coronary Artery Bypass Grafting

BackgroundCoronary artery bypass grafting (CABG) is an important and viable option for patients with symptomatic or life-threatening ischemic heart disease. Few papers have explored whether socioeconomic status is a significantly important determinant in late outcomes of CABG, and individual-level socioeconomic data were particularly scarce. This study was conducted to explore the impact of individual income level on clinical outcomes after CABG. MethodsThis nationwide longitudinal population-based study was conducted in South Korea using the National Health Insurance Service database. Overall, 29 810 adult patients who underwent first-time isolated CABG from 2005 to 2015 were included. The individual income level was stratified into 4 quartiles (Q1-Q4). The primary outcome was overall mortality. ResultsAfter adjustment for preoperative comorbidities, no significant difference in the in-hospital mortality rate was observed between the lowest (income Q1 group) and highest (income Q4 group) quartiles. The risk of overall mortality increased significantly with a reduction in income level, and having an income in the lowest quartile was a significant predictor of worse late mortality compared with the highest quartile (hazard ratio, 1.23; 95% CI, 1.17-1.30). Moreover, the overall incidence of stroke and myocardial infarction was significantly higher in the income Q1 group than in the income Q4 group. The median follow-up duration was 7.0 years (interquartile range, 4.1-10.2 years). ConclusionsPatients with a lower individual income level had an increased risk of the poorer long-term outcomes after CABG compared with the highest individual income level quartile.

Meta-Analysis of Aspirin for Primary Prevention of Stroke

Objective: This paper aims to evaluate the safety and efficacy of aspirin in primary stroke prevention by meta-analysis. Methods: By searching PubMed, Cochrane Library, Embase, MEDLINE, Web of Science, CNKI, China Biomedical Literature Database, VIP Database and Wanfang Database, we collected randomized controlled trials on aspirin for primary prevention of stroke. The retrieval time limit is from the establishment of the database to December 2021. Two researchers independently conducted literature search, screening, data extraction and quality evaluation, and Meta-analysis was performed using RevMan 5.3. Results: A total of 19 articles were included, including 220,636 subjects. Meta-analysis results show that long-term preventive use of aspirin can reduce the incidence of stroke [RR = 0.91, 95% CI (0.85, 0.98), P = 0.009], and reduce the incidence of ischemic stroke [RR = 0.84, 95% CI] (0.77, 0.91), P RR = 0.80, 95% CI (0.72, 0.88), P RR = 0.85, 95% CI (0.75, 0.97), P RR = 1.23, 95% CI (1.04, 1.46), P = 0.01] and gastrointestinal bleeding [RR = 1.62, 95% CI (1.35, 1.93), P RR = 0.97, 95% CI (0.93, 1.02), P = 0.20]. Conclusion: Long-term prophylactic use of aspirin can reduce the overall incidence of stroke, but there is also a risk of bleeding. The advantages and disadvantages of aspirin should be fully evaluated and strict screening should be carried out before medication, which can minimize adverse reactions and improve the safety and effectiveness of aspirin in the primary prevention of stroke.

At the Intersection of Race, Socioeconomics, and Chronic Illness: A Case and Frame Analysis of Two Survivor-Caregiver Dyads in the Aftermath of Stroke

ABSTRACT Although the overall incidence of stroke in the United States has decreased in recent years, the incidence of stroke among Black Americans has not changed. This has resulted in a widening gap between White and Black stroke survivors and their families. A variety of factors contribute to this inequity including social determinants of health (e.g., adverse life events, discrimination, neighborhood deprivation, lack of access to health care). This article uses a “case and frame” approach, through the lens of ecological systems theory, to illustrate how social determinants of health express themselves in two stroke survivor-caregiver dyads living in a large Midwestern city. We draw out implications for practice and policy in social work and related disciplines that focus on recognizing the impact of social determinants of health, developing culturally-specific interventions that mitigate unique stressors but that also leverage unique strengths, and building capacity for cultural competence and cross-cultural health communication within organizations.

Magnetic Resonance Imaging and Computed Tomography in Emergency Assessment of Patients with Suspected Acute Stroke: A Prospective Comparison

Background: Timely diagnosis has become important because the safety and efficacy of acute cerebral ischemia depend on rapid and accurate assessment and treatment within a few hours of the onset of symptoms.The overall incidence of stroke is about 2.4 per thousand people, with a small geographical difference. Studies have shown that the echo MRI gradient is as accurate as CT within 6 hours of the onset of symptoms in patients with acute stroke. Methodology: This study is a one-time prospective comparison of CT and MRI in acute stroke assessment. The study was conducted from April 2020 to September 2020at the Hayatabad Medical Complex in Peshawar, with the ethical approval of the hospital ethical review committee. Regardless of the onset date, the severity of symptoms, or final clinical diagnosis, a series of patients suspected of further referral to a stroke staff at the hospital are eligible. Results: Results showed that out of 178 patients referred for clinical suspicion of stroke, acute stroke corresponds to almost two-thirds of the final clinical diagnosis. MRI found 92 out of 178 acute strokes and 29 out of 178 CT. According to study results, the MRI has a higher frequency for detecting any acute stroke (ischemic or hemorrhagic) compared with CT (p <0.0001). All four readers agreed that 143 patients with MRI and 103 patients with CT respectively, 143 patients (80%, 76–84%) had an acute stroke. Conclusion: MRI is better for detecting acute ischemia than CT and can detect both acute and chronic bleeding. This should therefore be the preferred test method for accurate diagnosis of patients with suspected acute stroke. Samples of patients cover a variety of diseases that may arise in an emergency with a suspected stroke so that the results can be applied immediately in the clinic. Keywords: Magnetic Resonance Imaging, Computed tomography, Acutestroke.

Stroke risk in hypertrophic cardiomyopathy patients with atrial fibrillation: a nationwide database study.

Current treatment guidelines recommend anticoagulation for hypertrophic cardiomyopathy (HCM) with atrial fibrillation (AF) regardless of the CHA2DS2-VASc score. As aging and stroke risk factors (hypertension, diabetes mellitus) are confounders of ischemic stroke, young patients with a low stroke risk may not need anticoagulant treatment. This study aimed to determine the incidence of stroke and its risk factors in HCM patients with AF during a long-term follow-up. Using a national database, we retrospectively investigated 18,724 HCM patients from a systematic sample of 1,000,000 Taiwanese people between 1997 and 2013. The incidences of AF and stroke were estimated. Data were analyzed using Cox regression models. AF was identified in 598 patients (262 men, mean age 66.3±13.0 years) during a median follow-up of 7.0 years. The AF incidence in HCM patients was 5.83 per 1000 person-years, and the overall incidence of AF-associated stroke was 24.14 per 1000 person-years. The incidence of transient ischemic attack (TIA)/ischemic stroke varied from 20.41 to 60.55 per 1000 person-years, without proportionality to CHA2DS2-VASc score increase. Among patients aged <40 years, none experienced TIA/ischemic stroke. Univariate Cox regression models showed that age (p<0.001), prior TIA/ischemic stroke (p=0.02), and CHA2DS2-VASc score (p=0.003) were risk factors for TIA/ischemic stroke. Multivariate analysis indicated that age (hazard ratio 1.04, 95% confidence interval [CI] 1.02-1.06, p=0.001) and prior TIA/ischemic stroke (hazard ratio 2.82, 95% CI 1.27-6.25, p=0.011) were independently associated with TIA/ischemic stroke. Taiwanese patients with concomitant HCM and AF have a high stroke risk regardless of the CHA2DS2-VASc score. Aging is the main predictor. As the overall incidence of stroke was low in young patients, anticoagulants may not be needed in this subpopulation.

Impact of the COVID-19 outbreak on acute stroke pathways - insights from the Alsace region in France.

Background and purposeTo date, no study has attempted to quantify the impact of the COVID‐19 outbreak on the incidence and treatment of acute stroke.MethodsThis was a retrospective review of acute stroke pathway parameters in all three stroke units in the Alsace region during the first month of the outbreak (1–31 March 2020), using the similar period from 2019 as a comparator. A secondary detailed analysis of all stroke alerts and stroke unit admissions was performed in the centre with the largest case volume.ResultsCompared to the same period in 2019, in March 2020 there were 39.6% fewer stroke alerts and 33.3% fewer acute revascularization treatments [40.9% less intravenous thrombolysis (IVT) and 27.6% less mechanical thrombectomy (MT)]. No marked variation was observed in the number of stroke unit admissions (−0.6%). The proportion of patients with acute revascularization treatments (IVT or MT) out of the total number of stroke unit admissions was significantly lower in March 2020 (21.3%) compared to 2019 (31.8%), P = 0.034. There were no significant differences in time delays or severity of clinical symptoms for patients treated by IVT or MT, nor in the distribution of final diagnosis amongst stroke alerts and stroke unit admissions.ConclusionThese results suggest that the overall incidence of stroke remained the same, but fewer patients presented within the therapeutic time window. Increased public awareness and corrective measures are needed to mitigate the deleterious effects of the COVID‐19 outbreak on acute stroke care.

Ischemic Stroke in COVID-19 Patients: A Narrative Review

Coronavirus disease 2019 (COVID-19) is primarily known as a respiratory illness; however, a wide variety of symptoms and complications can also occur. It is associated with a small but clinically significant risk of stroke attributed to a hypercoagulable state. There is a need to summarize clinical characteristics, stroke mechanisms, and recommendations to prevent stroke in this population. The literature search was performed using PubMed, and after applying the inclusion and exclusion criteria, 6 published papers were found. The overall incidence of stroke in COVID patients can range from 1 to 2%, with high variability. COVID patients who developed stroke were mostly men, with a mean age above 60, and had a severe COVID-19 infection. In most cases, it was a large artery stroke. Acute Ischemic Stroke (AIS) in the setting of COVID-19 is associated with worse outcomes. It is very important to practice social distancing to prevent people from getting the infection. Prophylactic treatment should be given in patients with symptomatic COVID-19 infections, while asymptomatic carriers can prevent their chance of COVID-19 stroke by lifestyle changes and dietary modifications.

SUN-182 THE ROLE OF PERFUSION PRESSURE AND FLOW IN CARDIOPULMONARY BYPASS ASSOCIATED ACUTE KIDNEY INJURY

Acute kidney injury (AKI) after cardiopulmonary bypass (CPB) is associated with morbidity and mortality. The effect of perfusion flow and pressure on CPB-associated AKI is not well understood. Using multicenter registry data, this study aims to evaluate the role of perfusion pressure and flow in the development of CPB- associated AKI. The hypothesis of the study is that low flow is more strongly predictive of AKI than low pressure. Data from 31,749 adult patients who underwent surgery that employed the use of CPB over a 10-year period from January 2008 to January 2018 was retrospectively analysed. Data was obtained from the Perfusion Downunder Collaborative Database, which collates data from 9 participating hospitals in Australia and New Zealand. Primary predictor variables of interest were: time elapsed while perfusion flow was less than 1.6L/min/m2 and time elapsed while perfusion pressure was less than 30mmHg. The primary outcome variable was new post-operative AKI defined by the RIFLE criteria. Secondary outcomes included stroke and all cause mortality at time of discharge. The influence of flow and pressure on the primary outcome of AKI was estimated using separate multivariate models, with log transformation of both predictor and outcome required to meet model assumptions. The influence of flow and pressure on secondary outcomes of stroke and death were also estimated using separate multivariate models. The median age was 66 years. 72.4% (n=22,997) of patients were male and 27.6% (n=8,748) were female. The overall incidence of AKI of any RIFLE classification was 13.8% (n=4,071). The overall incidence of stroke was 1.5% (n=458) and death at time of discharge was 2.8% (n=818). In a multivariate linear regression model (Model 3‡) there is no association between low flow and AKI (β 0.00, CI 0.00-0.01, P=0.300). Likewise, in a multivariate linear regression model (Model 3‡) there is no association between low pressure and AKI (β 0.00, CI 0.01-0.02, P=0.098). Model 3|| demonstrates that in a multivariate logistic regression model, both low flow and low pressure are comparably predictive of stroke with an odds ratio (OR) of 1.48 (CI 1.19–1.84, P=0.000) and 1.57 (CI 1.44 – 1.72, P=0.000) respectively. Likewise, in a multivariate logistic regression model (Model 3◊), both low flow and pressure are predictive of death with OR of 1.26 (CI 1.07-1.49, P=0.005) and 1.17 (CI 1.06-1.30, P=0.002) respectively. In summary, neither flow less than 1.6L/min/m2, or pressure less than 30mmHg, had any power to predict post-operative creatinine in a fully adjusted model. Other non-operative factors were better predictors of AKI. These factors include a critical pre-operative state, ejection fraction and diabetes. By contrast, low flow and low pressure were both predictive in models for death and stroke. Neither the time elapsed while perfusion flow was less than 1.6L/min/m2 nor the time elapsed while perfusion pressure was less than 30mmHg were predictive of post- operative AKI. They were, however, predictive of both stroke and death.

Sex difference in the incidence of stroke and its corresponding influence factors: results from a follow-up 8.4 years of rural China hypertensive prospective cohort study

BackgroundFew studies investigate sex difference in stroke incidence in rural China hypertensive population.MethodsA total of 5097 hypertensive patients aged ≥35 years (mean age, 56.3 ± 11.2 years; 43.8% men) were included in our analysis with a median follow-up 8.4 years in Fuxin county of Liaoning province in China. Cox proportional hazard models were used to analyze the association between the potential factors and incident stroke.ResultsWe observed 501 new strokes (310 ischemic, 186 hemorrhagic, and 5 unclassified stroke) during the follow-up. The overall incidence of stroke was 1235.21 per 100,000 person-years; for men, the rates were 1652.51 and 920.80 for women. This sex difference in all stroke can be explained by approximately 25% through age, systolic blood pressure, body mass index, low-density lipoprotein-cholesterol, current smoking, current drinking, antihypertensive drugs, education and physical activity. Subgroup analysis indicated that in hemorrhagic stroke this sex difference was more remarkable (63.89% can be explained).ConclusionsThe incidence of stroke was higher in men than that in women and this difference was partly explained by several traditional cardiovascular risk factors.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Using real world data to assess cardiovascular outcomes of two antidiabetic treatment classes.

AIMTo evaluate the effect on cardiovascular outcomes of sodium-glucose co-transporter-2 (SGLT2) inhibitors in a real world setting by analyzing electronic medical records.METHODSWe used TriNetX, a global federated research network providing statistics on electronic health records (EHR). The analytics subset contained EHR from approximately 38 Million patients in 35 Health Care Organizations in the United States. The records of 46,909 patients who had taken SGLT2 inhibitors were compared to 189,120 patients with dipeptidyl peptidase (DPP) 4 inhibitors. We identified five potential confounding factors and built respective strata: elderly, hypertension, chronic kidney disease (CKD), and co-medication with either insulin or metformin. Cardiovascular events were counted as stroke (ICD10 code: I63) or myocardial infarction (ICD10: I21) occurring within three years after the first instance of the respective medication in the patients’ records.RESULTSOf the 46909 patients with SGLT2 inhibitors in their EHR, 1667 patients (3.6%) had an ICD code for stroke or for myocardial infarction within the first three years after the first instance of the medication. In the control group, there were 10680 events of 189120 patients (5.6%), which represents a risk ratio of 0.63 (95%CI: 0.60-0.66). The overall incidence of stroke or myocardial infarction in the strata with a potential confounding risk factor reached from 4.9% in patients taking metformin to 12.5% in the stratum with the highest risk (concomitant CKD). In all strata, the difference in risk of experiencing a cardiovascular event was similarly in favor of SGLT2 vs control, with Risk Ratio ranging from 0.62 to 0.81.CONCLUSIONReal world data replicated the results from randomized clinical trials, confirmed the cardiovascular advantages of SGLT2 inhibitors, and showed its applicability to the US population.

Incidence of thromboembolic events following atrial fibrillation catheter ablation and rate control strategies according to the kind of oral anticoagulation: A systematic review and meta-analysis

IntroductionAnticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation. MethodsPubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS2 score of included patients. ResultsOverall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5–3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group (p < 0.001). After stratification in 4 groups according to CHADS2 score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively (p < 0.001), for each CHADS2 cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group (p < 0.001). The incidence of all-cause mortality in the AF ablation group was significant lower than in the group of OAT (p < 0.0001). ConclusionAF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS2 score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.

Brain Magnetic Resonance Imaging Findings in Pediatric Patients Post Extracorporeal Membrane Oxygenation.

Neurologic complications can occur with extracorporeal membrane oxygenation (ECMO) due to several factors. Prior studies identified neonates as having unique risk factors and neuroimaging findings post ECMO. The aim of this study is to describe brain magnetic resonance imaging findings of pediatric patients treated with ECMO. We conducted a retrospective study of nonneonatal pediatric patients who underwent a comprehensive brain magnetic resonance imaging after ECMO between January 2000 and July 2015. We identified 47 pediatric patients in the study cohort with a median age of 8 months (interquartile range 3-170 months) and a median ECMO run duration of 7.15 days (interquartile range 3.8-10.3 days). Among indications for ECMO cannulation, 12 (25.5%) were cardiac, 23 (48.9%) were respiratory, and 12 (25.5%) were extracorporeal cardiopulmonary resuscitation cannulations. There were 33 (70.2%) veno-arterial cannulations of which 14 (42%) were transthoracic cannulations. There were 13 patients (27.7%) with an overall incidence of stroke: 8 patients had exclusive ischemic strokes, 2 had hemorrhagic strokes, and 3 had mixed types of stroke. The number of strokes in patients on veno-arterial ECMO was significantly decreased in patients undergoing transthoracic cannulation when compared with peripheral cannulation (7 vs. 42%, p = 0.05). Further study will be used to identify risk factors for neurological injury after ECMO and to look for outcome predictors based on neuroradiologic findings.

Increased risk of stroke in patients with osteoarthritis: a population-based cohort study.

Osteoarthritis (OA) is related to carotid atherosclerosis. Few studies have investigated the incidence of cerebrovascular diseases in patients with OA. Therefore, we conducted a population-based cohort study to determine the incidence and risk of stroke in patients with OA. We used data from Taiwan's Longitudinal Health Insurance Database 2000 (LHID2000) to investigate the incidence of stroke in 43,635 patients with OA newly diagnosed between 2002 and 2003. The non-osteoarthritis (non-OA) cohort comprised 43,635 people from the general population. The follow-up period was from the index date of OA to the date of censoring date or stroke diagnosis, or to the end of 2010. The overall incidence of stroke was 36% higher in the OA cohort than in the non-OA cohort, with an adjusted hazard ratio (aHR) of 1.10 (95% confidence interval [CI]=1.06-1.14) after adjustment for covariates. Men, age, comorbidity, non-selective nonsteroidal anti-inflammatory drugs (NSAIDs), and Cox-2 selective NSAIDs are independent risk factors of stroke. The OA adults with mild to moderate OA (aHR=1.97, 95% CI=1.70-2.28 for young adults; aHR=1.33, 95% CI=1.25-1.42 for middle-aged adults; aHR=1.16, 95% CI=1.12-1.21 for older adults) and severe OA (aHR=3.78, 95% CI=2.50-5.70 for young adults; aHR=1.34, 95% CI=1.16-1.56 for middle-aged adults; and aHR=1.01, 95% CI=0.92-1.10 for older adults) exhibited increased risks of stroke compared with their counterparts without OA. OA may be associated with a slightly increased risk of stroke.