Future Stroke Prevention Research Articles

CE-452778-1 LEFT ATRIAL MECHANICAL DYSFUNCTION AND THE INCIDENCE OF ATRIAL FIBRILLATION WITHIN 1 YEAR OF EMBOLIC STROKE OF UNKNOWN SOURCE

Atrial fibrillation (AF) is detected in a significant proportion of patients with embolic stroke of unkown source (ESUS) on subsequent cardiac monitoring and represents an indication for anticoagulation to prevent future stroke in these patients. Left atrial mechanical dysfunction often precedes development of atrial fibrillation and may represent an upstream marker which can readily be assessed at the point of care to inform decisions about future stroke prevention in people with ESUS. To evaluate the association between left atrial mechanical dysfunction, measured by left atrial emptying fraction (LAEF) and reservoir strain (LARS), and incident atrial fibrillation in patients with ESUS. Patients with interpretable echocardiograms who received an implantable loop recorder for ESUS at a tertiary care medical center between 2015 and 2022 were included and followed for 1 year. LAEF and LARS were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, and vascular disease were ascertained by review of hospital medical records. Incident AF post ESUS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. 167 patients (mean age 74.4 years, 52.1% female) were followed for 1 year after ESUS. AF was detected in 49 (20.3%) patients. Patients who developed AF had lower LAEF (46.78% vs 57.50%, P<0.01) and LARS (24.33% vs 31.60%, P<0.01) compared to those who did not develop AF. LAEF and LARS were independently associated with AF within 1 year of ESUS (Table). Left atrial mechanical dysfunction, detected by meeasurement of left atrial reseervoir strain and emptying fraction, is independently associated with the incidence of atrial fibrillation within 1 year of ESUS.

Smartphone application-supported validation of three automatic devices for self-measurement of blood pressure according to the European Society of Hypertension International Protocol revision 2010: the Omron HEM-7120, Yuwell YE680A and Cofoe KF-65B.

BackgroundAccurate measurement of blood pressure (BP) is crucial to hypertension control and prevention of future stroke and heart attack. All BP measuring devices must be validated independently in the clinical setting.ObjectiveTo validate the accuracy of three automatic upper arm devices (Omron HEM-7120, Yuwell YE680A and Cofoe KF-65B) for self-measurement of BP in Chinese adults with arm size of 22–32 cm.MethodsThe validation was conducted independently for each of the three devices according to the European Society of Hypertension International Protocol revision 2010 (ESH-IP revision 2010), with the facilitation of a designated smartphone application. Subjects were recruited from those attending Beijing Anzhen Hospital for routine physical examination and clinic visits. For each device, BP was measured sequentially in 33 adults using a mercury sphygmomanometer (two observers) and the test device (one supervisor) with seven measurements alternating between observers and the device, which generated a total of 99 before/after paired values for SBP and DBP separately. The judgments were made based on the distribution of the paired difference among the 99 measurements (Part 1) and among the 33 subjects (Part 2). To pass, a device must achieve all the minimum Pass requirements in Part 1 and Part 2 for both SBP and DBP (Part 3).ResultsOnly HEM-7120 achieved the part 1 and part 2 targets for both SBP and DBP. KF-65B achieved the DBP targets of part 1 and part 2 but failed for SBP. YE680A only achieved the DBP targets of part 2 but failed for all others. The findings also indicated that the devices had higher SBP readings (1.3 mmHg, 1.0 mmHg and 4.1 mmHg higher for HEM-7120, YE680A and KF-65B, respectively) and lower DBP readings (2.0 mmHg, 1.1 mmHg and 3.3 mmHg lower, respectively) when compared to the mercury sphygmomanometer.ConclusionsThe Omron HEM-7120 passed the requirements of the ESH-IP 2010 revision, while the Yuwell YE680A and Cofoe KF-65B failed (part 3).

Prevalence of Stroke and Stroke Risk Factors in a South-Western Community of Nepal

BackgroundStroke related studies in Nepal are primarily hospital-based and mainly from the capital city. ObjectivesWe aimed to estimate the prevalence of stroke and stroke risk factors in the South-Western community of Nepal. MethodsA cross-sectional study was conducted from May to August 2018 among 549 randomly selected Nepalese participants from diverse ethnicity, aged ≥15 years, in a region with the availability of neurological support facilities. Data were collected using a stroke questionnaire designed for the purpose. Stroke was identified by enumerators using the Balance-Eyes-Face-Arms-Speech-Time (BEFAST) scale, and a senior neurologist confirmed it. We assessed the presence of major risk factors associated with stroke. ResultsThe crude and age-standardised prevalence of stroke were 2368 and 2967 per 100,000 respectively. Of all the surveyed participants, 61% (n=335) reported consumption of full-fat dairy products >3 days per week, 87.6% (n=481) reported a high intake of salt (>5 g/day), 83.6% (n=459) with a low intake of fruits and vegetables (<400 g/day), 45.2% (n=248) with perceived stress related to work or home, 51.6% (n=283) with financial stress (283, 51.6%), 86.7% (n=457) with low high-density lipoprotein, 96.2% (n=507) with high blood urea nitrogen, 47.1% (n=356) were either overweight or obese 20.4% (n=112) with hypertension and 6.2% (n=34) with diabetes. ConclusionsThe prevalence of stroke in the community of the South-Western part of Nepal is relatively higher than that estimated in South-Asia and global context. Our findings suggest an urgent community intervention, particularly with healthy lifestyles changes for future stroke prevention in the high-risk group.

Promising Biomarker Candidates for Cardioembolic Stroke Etiology. A Brief Narrative Review and Current Opinion.

Determining the cause of stroke is considered one of the main objectives in evaluating a stroke patient in clinical practice. However, ischemic stroke is a heterogeneous disorder and numerous underlying disorders are implicated in its pathogenesis. Although progress has been made in identifying individual stroke etiology, in many cases underlying mechanisms still remain elusive. Since secondary prevention strategies are tailored toward individual stroke mechanisms, patients whose stroke etiology is unknown may not receive optimal preventive treatment. Cardioembolic stroke is commonly defined as cerebral vessel occlusion by distant embolization arising from thrombus formation in the heart. It accounts for the main proportion of ischemic strokes, and its share to stroke etiology is likely to rise even further in future decades. However, it can be challenging to distinguish cardioembolism from other possible etiologies. As personalized medicine advances, stroke researchers' focus is increasingly drawn to etiology-associated biomarkers. They can provide deeper insight regarding specific stroke mechanisms and can help to unravel previously undetected pathologies. Furthermore, etiology-associated biomarkers could play an important role in guiding future stroke prevention strategies. To achieve this, broad validation of promising candidate biomarkers as well as their implementation in well-designed randomized clinical trials is necessary. This review focuses on the most-promising candidates for diagnosis of cardioembolic stroke. It discusses existing evidence for possible clinical applications of these biomarkers, addresses current challenges, and outlines future perspectives.

Temporal Trends in Stroke Incidence Over Time by Sex and Age in the GCNKSS

Background and Purpose- Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods- Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results- Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215-242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163-185) in 2015 (P<0.05), compared with 282 (95% CI, 263-301) in 1993/1994 to 211 (95% CI, 198-225) in 2015 (P<0.05) in men. Incidence rates decreased between the first and last study periods in both sexes for IS but not for intracerebral hemorrhage or subarachnoid hemorrhage. Significant decreases in stroke incidence occurred between the first and last study periods for both sexes in the 65- to 84-year age group and men only in the ≥85-year age group; stroke incidence increased for men only in the 20- to 44-year age group. Conclusions- Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage.

Arterial wall contrast enhancement in progressive moyamoya disease.

The purpose of this study was to evaluate chronological patterns of arterial wall contrast enhancement in contrast-enhanced high-resolution MRI (CE-HR-MRI) in patients with moyamoya disease (MMD). The authors performed a blinded analysis of clinical and imaging data from MMD patients. Data were analyzed chronologically for each patient and the intensity of arterial wall enhancement was correlated with the clinical and imaging-based progression status of the disease. A total of 31 MMD patients and 61 imaging time points were included. CE-HR-MRI results were available for 56 time points, representing 112 hemispheric analyses. No arterial wall contrast enhancement (grade 1) was seen in 54 (48%) of the analyses, mild enhancement (grade 2) in 24 (21%), moderate enhancement (grade 3) in 15 (13%), and strong (grade 4) mainly concentric arterial wall contrast enhancement in 19 (17%). Grade 4 contrast enhancement was significantly (p < 0.001) associated with clinical disease progression within 6 months (before or after the MRI) compared to grades 1-3, with positive and negative predictive values of 0.8 and 0.88, respectively. Grades 1 and 2 (no contrast enhancement and only mild contrast enhancement) were highly predictive for stable disease (negative predictive value: 0.95). A specific chronological increasing and decreasing pattern of arterial wall contrast enhancement associated with "beginning" as well as progression of angiopathy occurs in MMD patients. In clinical practice, CE-HR-MRI of the arterial wall may help to identify patients at risk of new strokes caused by disease progression and hence impel early treatment for future stroke prevention. Understanding of this temporary enhancement of the arterial wall might also bring new insights into the etiology of MMD.

Patent Foramen Ovale Closure in the Setting of Cryptogenic Stroke: A Meta-Analysis of Five Randomized Trials

The clinical benefit of patent foramen ovale (PFO) closure after cryptogenic stroke has been a topic of debate for decades. Recently, 3 randomized controlled trials of PFO closure in patients with cryptogenic stroke demonstrated a significantly reduced risk of recurrent stroke compared with standard medical therapy alone. This meta-analysis was performed to clarify the efficacy of PFO closure for future stroke prevention in this population. A systematic literature search was undertaken. Published pooled data from 5 large randomized clinical trials (CLOSE, RESPECT, Gore REDUCE, CLOSURE I, and PC) were combined and then subsequently analyzed. Enrolled patients with cryptogenic stroke were assigned to receive standard medical care or to undergo endovascular PFO closure, with a primary outcome of reduction in stroke recurrence rate. Secondary outcomes included rates of transient ischemic attack (TIA), composite outcome of stroke, TIA, and death from all causes, and rates of atrial fibrillation events. We analyzed data for 3412 patients. Transcatheter PFO closure resulted in a statistically significant reduced rate of recurrent stroke, compared with medication alone. Patients undergoing closure were 58% less likely to have another stroke. The number needed to treat with PFO closure to reduce recurrent stroke for 1 patient was 40. Endovascular PFO closure was associated with a reduced risk of recurrent stroke in patients with a prior cryptogenic cerebral infarct. Although the absolute stroke reduction was small, these findings are clinically significant, given the young age of this patient population and the patients' lifetime risk of recurrent stroke.

Meta-analysis of the surgical outcomes of symptomatic moyamoya disease in adults.

OBJECTIVE The purpose of this study was to evaluate treatment outcomes of future stroke prevention, perioperative complications, and angiographic revascularization in adults with symptomatic moyamoya disease (MMD) according to treatment modalities and surgical techniques. METHODS A systemic literature review was performed based on searches of the PubMed, Embase, and Cochrane Central databases. A fixed-effects model was used in cases of heterogeneity less than 50%. Publication bias was determined by Begg's funnel plot, Egger's test of the intercept, and the Begg and Mazumdar rank correlation test. RESULTS Eleven articles were included in the meta-analysis. Bypass surgery significantly decreased the future stroke events compared with conservative treatments in adult MMD (odds ratio [OR] 0.301, p < 0.001). Direct bypass showed better future stroke prevention than indirect bypass (OR 0.494, p = 0.028). There was no meaningful difference in perioperative complications between direct and indirect bypass (OR 0.665, p = 0.176). Direct bypass was associated with better angiographic outcomes than indirect bypass (OR 6.832, p < 0.001). CONCLUSIONS Bypass surgery can be effective in preventing future stoke events in adults with MMD. Direct bypass seems to provide better risk reduction with respect to stroke than indirect bypass in these patients.

Stenting in Intracranial Stenosis: Current Controversies and Future Directions.

Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) are a last resort for patients with high-grade intracranial stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.

Plaque Inflammation and Unstable Morphology Are Associated With Early Stroke Recurrence in Symptomatic Carotid Stenosis

Although symptomatic carotid stenosis is associated with 3-fold increased risk of early stroke recurrence, the pathophysiologic mechanisms of high early stroke risk have not been established. We aimed to investigate the relationship between early stroke recurrence after initial symptoms and histological features of plaque inflammation and instability in resected carotid plaque. Carotid endarterectomy tissue from consecutive patients with ipsilateral stenosis≥50% and recent symptoms were analyzed using a validated histopathologic algorithm (Oxford Plaque Study [OPS] system). Nonprocedural stroke recurrence before carotid endarterectomy was ascertained at 7, 28, and 90 days after initial symptoms. Among 44 patients meeting eligibility criteria, 27.3% (12/44) had stroke recurrence after initial stroke/transient ischemic attack but before carotid endarterectomy. Compared with patients without recurrence, stroke recurrence was associated with dense macrophage infiltration (OPS grade≥3; 91.7% versus 37.5%; P=0.002), extensive (>25%) fibrous cap disruption (90.9% versus 37%; P=0.004), neovascularization (OPS grade≥2; 83.3% versus 43.8%; P=0.04), and low plaque fibrous content (OPS grade<2; 50% versus 6.3%; P=0.003). Early recurrence rates were 82.3% (confidence interval, 49.2%-98.8%) in patients with extensive plaque macrophage infiltration (OPS grade≥3) compared with 22.2% (confidence interval, 3.5%-83.4%) in those with OPS grade<3 (log-rank P=0.009). On multivariable Cox regression, including OPS macrophage grade (≥3 or <3), age, and severity of stenosis (50%-69% or ≥70%), plaque inflammation was the only variable independently predicting stroke recurrence (adjusted hazard ratio, 9; confidence interval, 1.1-70.6; P=0.04). Plaque inflammation and other vulnerability features were associated with highest risk of stroke recurrence and may represent therapeutic targets for future stroke prevention trials.

Standards of practice and reporting standards for carotid artery angioplasty and stenting

Every year almost 800 000 people in the USA suffer a new or recurrent stroke, and stroke is the third leading cause of death with over 140 000 deaths in...

Middle cerebral artery pulsatility index and cognitive improvement after carotid endarterectomy for symptomatic stenosis.

Transcranial Doppler (TCD) is frequently used to evaluate peripheral cerebral resistance and cerebral blood flow (CBF) in the middle cerebral artery prior to and during carotid endarterectomy (CEA). Patients with symptomatic carotid artery stenosis may have reduced peripheral cerebral resistance to compensate for inadequate CBF. The authors aim to determine whether symptomatic patients with reduced peripheral cerebral resistance prior to CEA demonstrate increased CBF and cognitive improvement as early as 1 day after CEA. Fifty-three patients with symptomatic CEA were included in this observational study. All patients underwent neuropsychometric evaluation 24 hours or less preoperatively and 1 day postoperatively. The MCA was evaluated using TCD for CBF mean velocity (MV) and pulsatility index (PI). Pulsatility index ≤ 0.80 was used as a cutoff for reduced peripheral cerebral resistance. Significantly more patients with baseline PI ≤ 0.80 exhibited cognitive improvement 1 day after CEA than those with PI > 0.80 (35.0% vs 6.1%, p = 0.007). Patients with cognitive improvement had a significantly greater increase in CBF MV than patients without cognitive improvement (13.4 ± 17.1 cm/sec vs 4.3 ± 9.9 cm/sec, p = 0.03). In multivariate regression model, a baseline PI ≤ 0.80 was significantly associated with increased odds of cognitive improvement (OR 7.32 [1.40-59.49], p = 0.02). Symptomatic CEA patients with reduced peripheral cerebral resistance, measured as PI ≤ 0.80, are likely to have increased CBF and improved cognitive performance as early as 1 day after CEA for symptomatic carotid artery stenosis. Revascularization in this cohort may afford benefits beyond prevention of future stroke. Clinical trial registration no: NCT00597883 ( ClinicalTrials.gov ).

Prevalence of stenoses and occlusions of brain-supplying arteries in young stroke patients

Atherosclerosis is believed to be a minor cause of TIA and stroke in younger and middle-aged patients. However, data from large cohorts are limited. This study investigates the prevalence of extracranial and intracranial atherosclerosis in stroke and TIA patients aged 18-55 years in the multinational sifap1 study. From the sifap1 cohort (n = 5,023), we analyzed a subset of patients with complete data from carotid ultrasound studies. Patients with arterial dissections, vasculitis, and mobile thrombi were excluded. Among the remaining 2,187 patients (men: n = 1,319; 18-44 years: n = 744), intracranial arteries were additionally examined with ultrasonography in 1,612 patients (73.7%). Patients were stratified by sex and age groups (younger: 18-44 years; middle-aged: 45-55 years). In patients with ischemic stroke, the overall prevalence of carotid artery stenoses and occlusions was 8.9% (younger: 4.9%; middle-aged: 11.0%), of which 81% were symptomatic. Nonstenotic carotid plaques were more common in men than in women (15.8% vs. 7.7%; p < 0.001), and in middle-aged than in younger patients (17.0% vs. 4.9%; p < 0.001). Supratentorial intracranial artery stenoses and occlusions amounted to 11.8%. Supratentorial stenoses occurred more frequently in middle-aged patients (13.0% vs. 7.8%; p < 0.001), whereas occlusions were equally common (both 3.2%; not significant). We observed a substantial proportion of atherosclerotic carotid artery stenoses and occlusions in younger stroke patients. Intracranial stenoses and occlusions were even more prevalent than extracranial carotid artery disease. Together with nonstenotic plaques, one-fifth of patients (21.2%) had symptomatic or asymptomatic large-artery atherosclerosis, which should encourage future stroke prevention campaigns to target risk factor modification in young people.

Abstract TP407: Participant Satisfaction With a Lifestyle Management Program in the SAMMPRIS Clinical Trial

Background: SAMMPRIS was the first secondary prevention stroke trial to provide a lifestyle modification program to all clinical trial participants. We sought to determine if SAMMPRIS participants would have a high level of satisfaction with the compulsory lifestyle program. Methods: Patients enrolled in SAMMPRIS who were actively participating in the lifestyle modification program for &gt; 12 weeks were mailed anonymous surveys. The survey was conducted by the company that administered the lifestyle program and the data was provided to the authors. The survey measured 6 constructs: consistency of program delivery, quality of materials, confidentiality, coach-participant relationship, individualization, and time efficiency, with 2 statements addressing each construct. Participants were asked to respond to 2 variables, “importance” and “satisfaction”, for each statement using five-point Likert-type scales (5 = high; 1 = low). An adjusted needs index (ANI) was computed for each statement: [(mean importance - mean satisfaction) x (mean importance)]. Participants were also asked to respond (“strongly agree” or “strongly disagree”) to 2 statements related to their overall evaluation of the program and if they would recommend the program to others. Results: Surveys were completed by 199/327 (61%) participants. For the 6 constructs, mean scores for “importance” ranged from 4.36 - 4.73 and mean scores for “satisfaction” ranged from 4.38 - 4.69. The coach-participant relationship rated highest for both “importance” and “satisfaction”. ANIs for 8 of 12 statements were either 0 or negative values, indicating that expectations were met or exceeded. Individualization of the program had the highest ANI at 0.45. Statements regarding overall evaluation received high ratings (means 4.65, 4.66). Conclusion: SAMMPRIS clinical trial participants had a high level of satisfaction with the study’s lifestyle management program. These data, coupled with final data from SAMMPRIS showing that compliance with the program resulted in improved control of risk factors, would strongly support the use of lifestyle programs in future stroke prevention clinical trials and in clinical practice.

Abstract 10: Rising Trend of Ischemic Stroke in the Young

Background: Stroke in patients under 45 years of age occurs less frequently than in older patients but its impact on the individual and society is greater. Recent studies have reported decreasing trends of acute ischemic stroke hospitalization. However, it is less clear what the trends are in different age groups and across different races. We sought to determine trends of ischemic stroke by age, gender and race in a large multi-ethnic population. Methods: Northern California Kaiser Permanente (KPNC) is a large multi-ethnic health care system that serves over 3 million members. Membership demographics, socio-economic and racial-ethnic distributions are representative of California. Study patients were identified by primary discharge ICD-9 codes (433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91 and 436) for the period of January 2000 - December 2008. Only one stroke per person per year was included in the analyses. Age-adjusted stroke rates standardized to the 2000 US Census population were calculated. Poisson regression analysis was used to examine trend data. Results: From 2000-2008, a total of 25,433 ischemic strokes and 28,438,488 person-years were included in the analyses. Age-adjusted rates of ischemic stroke decreased from 203 to 145 per 100,000 during this time (p&lt;0.001). Rates decreased across all races during study period with the greatest drop among African Americans (from 313 to 261 per 100,000; p&lt;0.001). Decreasing trends were similar between males and females across races. However, ischemic stroke rates among ages 25-44 were on the rise during this time (p&lt;0.001), in particular for Black (from 17 to 39 per 100,000) and for Asian/Pacific Islanders (from 5 to 11 per 100,000) [ Figure ]. Conclusions: While the overall trend in KPNC showed a decrease in age-adjusted rates for ischemic stroke from 2000-2008, this was mainly true for age ≥ 65 years. There was an alarming rise in the number of ischemic strokes among patients age 25-44 years. Further studies to assess the trends of vascular risk factors such as obesity, hypertension and diabetes are needed to identify future stroke prevention targets in this age group.

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

Obstructive Sleep Apnea–Hypopnea and Incident Stroke

Although obstructive sleep apnea is associated with physiological perturbations that increase risk of hypertension and are proatherogenic, it is uncertain whether sleep apnea is associated with increased stroke risk in the general population. To quantify the incidence of ischemic stroke with sleep apnea in a community-based sample of men and women across a wide range of sleep apnea. Baseline polysomnography was performed between 1995 and 1998 in a longitudinal cohort study. The primary exposure was the obstructive apnea-hypopnea index (OAHI) and outcome was incident ischemic stroke. A total of 5,422 participants without a history of stroke at the baseline examination and untreated for sleep apnea were followed for a median of 8.7 years. One hundred ninety-three ischemic strokes were observed. In covariate-adjusted Cox proportional hazard models, a significant positive association between ischemic stroke and OAHI was observed in men (P value for linear trend: P = 0.016). Men in the highest OAHI quartile (>19) had an adjusted hazard ratio of 2.86 (95% confidence interval, 1.1-7.4). In the mild to moderate range (OAHI, 5-25), each one-unit increase in OAHI in men was estimated to increase stroke risk by 6% (95% confidence interval, 2-10%). In women, stroke was not significantly associated with OAHI quartiles, but increased risk was observed at an OAHI greater than 25. The strong adjusted association between ischemic stroke and OAHI in community-dwelling men with mild to moderate sleep apnea suggests that this is an appropriate target for future stroke prevention trials.

Obstructive Sleep Apnea–Hypopnea and Incident Stroke: the Sleep Heart Health Study

Rationale: Although obstructive sleep apnea is associated with physiological perturbations that increase risk of hypertension and are proatherogenic, it is uncertain whether sleep apnea is associated with increased stroke risk in the general population. Objectives: To quantify the incidence of ischemic stroke with sleep apnea in a community-based sample of men and women across a wide range of sleep apnea. Methods: Baseline polysomnography was performed between 1995 and 1998 in a longitudinal cohort study. The primary exposure was the obstructive apnea–hypopnea index (OAHI) and outcome was incident ischemic stroke. Measurements and Main Results: A total of 5,422 participants without a history of stroke at the baseline examination and untreated for sleep apnea were followed for a median of 8.7 years. One hundred ninety-three ischemic strokes were observed. In covariate-adjusted Cox proportional hazard models, a significant positive association between ischemic stroke and OAHI was observed in men (P value for linear trend: P = 0.016). Men in the highest OAHI quartile (>19) had an adjusted hazard ratio of 2.86 (95% confidence interval, 1.1–7.4). In the mild to moderate range (OAHI, 5–25), each one-unit increase in OAHI in men was estimated to increase stroke risk by 6% (95% confidence interval, 2–10%). In women, stroke was not significantly associated with OAHI quartiles, but increased risk was observed at an OAHI greater than 25. Conclusions: The strong adjusted association between ischemic stroke and OAHI in community-dwelling men with mild to moderate sleep apnea suggests that this is an appropriate target for future stroke prevention trials.

The Cerebrovascular Attitudes and Beliefs Scale (CABS-R): The Factor Structure and Psychometric Properties of a Tool for Assessing Stroke-Related Health Beliefs

Worldwide stroke is serious problem and one that necessitates continued efforts towards prevention. The health belief model suggests that improvements in prevention will follow from incorporating strategies that change beliefs, but this approach relies on the availability of tools for measuring such change. The Cerebrovascular Attitudes and Beliefs Scale (CABS-R) was developed to meet this need. The purpose of this study was to investigate the psychometric properties of the CABS-R. In 2007, 126 Brisbane residents aged 50 years and older completed the CABS-R. One month later, 70 participants completed the CABS-R again. Internal consistency, test-retest, and exploratory factor analyses were performed on subscales completed by >60 participants. Analyses showed that the CABS-R has moderate-to-good internal consistency and that scores are relatively stable over time. A four-factor solution was identified, suggesting that the CABS-R validly assesses stroke susceptibility and seriousness and the perceived benefits of and barriers to exercise and weight loss for stroke prevention. This study shows that the CABS-R is useful to gauge changes in stroke beliefs over time. Consistent with the model, a four factor solution was found. The CABS-R may be a useful inclusion in future stroke prevention programs.

The management of patients with patent foramen ovale and stroke

The management of patients with patent foramen ovale (PFO) and stroke remains uncertain. What is known is that PFO is a very common finding in the general population. The risk of initial and recurrent stroke in individuals with PFO is relatively low. With the advent of transesophageal echocardiography, PFO is more commonly being diagnosed. There are insufficient data to support a benefit of warfarin over aspirin in preventing recurrent stroke in most patients with PFO. In those with PFO and a history of a procoagulant state or deep venous thrombosis, anticoagulation may be indicated after weighing the risks of anticoagulation against potential benefits in preventing recurrent stroke. PFO closure does not guarantee the prevention of future stroke and should be addressed case by case, with consideration of patients for entry into ongoing clinical trials of safety, efficacy, and durability.