Previous Transient Ischemic Attack Research Articles

The association between vertebral artery hypoplasia and fetal-type variants of the posterior cerebral artery with imaging findings among patients with posterior circulation stroke: A single-center cross-sectional study.

The present study investigated the correlation between vertebral artery hypoplasia and fetal-type variations of posterior cerebral arteries with stroke patterns and imaging findings in individuals with posterior circulation ischemic stroke. In this cross-sectional study, patients with symptoms of acute ischemic stroke in the posterior circulation system referred to Ghaem Hospital in Mashhad between 2016 and 2022 were investigated. Demographic data, including age, gender, systemic diseases, history of previous stroke or transient ischemic attacks, and clinical manifestations of patients, were recorded using questionnaires and checklists from patient files. The results of imaging studies, including magnetic resonance imaging and computed tomography angiography, were also recorded. The obtained data were analyzed by SPSS statistical software. Among 974 patients suffering from posterior circulation ischemic stroke, 155 patients with an average age of 60.44 ± 13.95 years were included in the study, out of which 97 patients (62.6%) were male. Unilateral vertebral artery hypoplasia on the right, left, and bilateral hypoplasia was present in 67 (43.2%), 35 (22.6%), and 5 (3.2%) patients, respectively. There were complete unilateral fetal origin on the right in 38 (24.5%), complete unilateral on the left in 12 (7.7%), partial unilateral on the right in 12 (7.7%), partial unilateral on the left in 6 (3.9%), complete bilateral in 14 (9%), and partial bilateral in 8 (5.2%) patients. There was no significant relationship between vertebral artery hypoplasia and PCA fetal-type variants with different ischemia locations and infarct patterns (p > 0.05). Also, there was no significant relationship between the age and gender of patients with ischemia location and infarct pattern (p > 0.05). Despite previous evidence showing a relation between vertebral artery hypoplasia and PCA fetal-type variants as risk factors for PC stroke, the present study did not establish a significant correlation between these factors and the location of ischemia and infarct patterns.

How far back do we need to look to capture diagnoses in electronic health records? A retrospective observational study of hospital electronic health record data

ObjectivesAnalysis of routinely collected electronic health data is a key tool for long-term condition research and practice for hospitalised patients. This requires accurate and complete ascertainment of a broad range...

HPB P17 Preoperative cardiovascular disease and outcomes ofpancreatoduodenectomy performed for malignancy

Abstract Background Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy (PD) remains a high-risk operation. Patients with pre-existing cardiovascular disease (CVD) are known to be at increased risk of perioperative morbidity and mortality. Evidence is lacking on the impact of CVD on long-term outcomes. This study aimed to compare the outcomes of PD patients with preoperative CVD to those without. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing CVD included any of the following: hypertension (HTN), atrial fibrillation (AF), other cardiac arrhythmia, ischaemic heart disease (IHD), previous cardiovascular surgery, heart failure, peripheral vascular disease (PVD), previous stroke, previous transient ischaemic attack (TIA), pulmonary HTN, deep vein thrombosis, valve disease, cardiomyopathy, subarachnoid haemorrhage, peri-/myocarditis and myocardial infarction. Several outcomes were compared: length of stay, 30-day readmission, 90-day mortality, unplanned return to theatre rate, and five-year survival. Results From 1484 cases, 590 patients (39.8%) had pre-existing CVD. HTN, AF, other cardiac arrhythmia, IHD, previous cardiovascular surgery, heart failure and PVD affected 33.0%, 3.6%, 1.0%, 5.3%, 1.9%, 1.3% and 1.5% of patients, respectively. Remaining pathologies surmounted to <1%. 30-day readmission (10.5% vs 8.1%, p=0.1), 90-day mortality (4.4% vs 3.2%, p=0.3), unplanned return to theatre (5.2% vs 4.8%, p=0.7) and five-year survival (31.2% vs 32.1%, p=0.7) were similar between the patient groups, however, median LoS was significantly longer in those with CVD (14 vs 12 days, p<0.0001). Similar results were obtained when hypertension was not classified as a cardiovascular comorbidity. Conclusions In our multicentre study of PD outcomes, patients with a preoperative cardiovascular comorbidity had longer length of stay than those who did not but the other studied outcomes were unaffected.

Abstract 16631: Isolated Cardiac Sarcoidosis Presenting as Recurrent Transient Ischemic Attacks

Background: Cardiac sarcoidosis (CS) is a rare disease that can present with a variety of clinical scenarios including, heart failure and sudden death. We present a case of isolated CS presenting as recurrent transient ischemic attacks (TIA) in a previously asymptomatic patient. Description of Case. A 54-year-old female with a history of two previous TIAs presented 30 minutes after the onset of left-sided facial droop and incomprehensible speech. CT and MRI brain did not show acute infarction. ECG showed a right bundle branch block pattern. Transthoracic echocardiogram (TTE) showed an abnormal global longitudinal strain of 12.8%, a left ventricular ejection fraction of 40%, segmental wall motion abnormalities involving the apex and basal inferior walls, and swirling of contrast at the apex. She had no previous history of cardiomyopathy. CTA was unrevealing for coronary artery disease but a cardiac MRI showed areas of late gadolinium enhancement and a RV wall aneurysm. PET scan revealed multifocal patchy nodular areas of FDG uptake within the myocardium. A diagnosis of isolated CS was made. At a three-month follow-up, TTE showed a new apical thrombus measuring 0.8cm x 0.6 cm. The patient was started on anticoagulation with the eventual resolution of the thrombus. She had no further ischemic events. Discussion. TIAs and ischemic stroke are extremely rare complications of CS and are largely attributed to cardioembolic phenomena, in the absence of systemic disease. Cardiac structural changes that lead to arrhythmias, hypokinesis, and stasis with clot formation largely explain embolic events in these patients. In addition, evidence suggests that the inflammatory cytokines, such as IFN gamma and IL-12, released by the sarcoid granuloma may also have an independent role in clot formation. The combination of stagnant flow in akinetic areas and a strong inflammatory bed of cytokines led to recurrent TIAs in this patient and the apical thrombus that was later identified.

Comparison of Aspirin and P2Y12 Inhibitors for Secondary Prevention of Ischaemic Stroke: A Systematic Review and Meta-analysis.

P2Y12 inhibitors have been widely used as an alternative to aspirin in clinical practice for secondary stroke prevention. We aimed to compare the efficiency and safety of P2Y12 inhibitors and aspirin for stroke prevention in patients with previous stroke or transient ischaemic attack (TIA). PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched. All randomized trials that compared P2Y12 inhibitors with aspirin among patients with stroke were included. The primary efficacy outcomes of our meta-analysis included stroke, vascular events, and all-cause death. The primary safety outcome was minor or major bleeding events. The search identified 4 randomized clinical trials comparing P2Y12 inhibitors with aspirin for secondary stroke prevention that collectively enrolled 24508 patients (12253 received P2Y12 inhibitor and 12255 received aspirin). Pooled results from the random-effects model showed that there were no significant differences in the risk of any stroke (OR 0.90 (0.78-1.04); I²=56.9%), vascular event (OR 0.91 (0.74-1.13); I²=78.3%), all-cause death (OR 0.98 (0.83-1.17); I²=0%), or minor or major bleeding (OR 1.13 (0.70-1.82); I²=79%) among patients who received a P2Y12 inhibitor or aspirin. P2Y12 inhibitors were associated with a significantly lower risk of recurrent ischaemic stroke (OR 0.84 (0.73- 0.96); I²=25%) than aspirin. This meta-analysis suggests that P2Y12 inhibitors are more effective than aspirin in preventing recurrent ischaemic stroke among ischaemic stroke patients despite the absence of any effect on a new ischaemic or haemorrhagic stroke, a new clinical vascular event, all-cause death, and major or minor bleeding events.

Readmissions After Left Atrial Appendage Closure in Patients With Previous Ischemic Stroke or Transient Ischemic Attack

BackgroundWe examined the frequency and risk factors associated with readmission after left atrial appendage closure (LAAC) in patients with and without previous ischemic stroke and/or transient ischemic attack (TIA). MethodsHospitalizations for LAAC were identified from the US National Readmission Database, 2016-2018. The primary outcome was the first unplanned readmission after LAAC, with readmission times stratified into those occurring within 0 to 30 days vs within 31 to 180 days. Patients were stratified based on the history of previous stroke and/or TIA. ResultsOf 12,901 discharges after LAAC, 28% had previous stroke and/or TIA, and 8.2% had a readmission within 30 days while 18% had a readmission within 31 to 180 days. The rates of in-hospital complications and readmissions at both periods were not significantly different between individuals with vs without previous stroke and/or TIA. Cardiac causes accounted for 28% of readmissions within 30 days and 32% of those within 31 to 180 days, and congestive failure, bleeding, and infections were the most common readmission diagnoses. New stroke and/or TIA accounted for 4% and 6% of the total noncardiac readmissions within 30 days and 31 to 180 days, respectively, and the incidence was higher among those with previous stroke and/or TIA. Female sex and index hospitalization length of stay (LOS) > 1 day were factors independently associated with readmission within 30 days, whereas LOS, diabetes, renal disease, chronic obstructive pulmonary disease, and anemia were among the factors associated with readmissions within 31 to 180 days. ConclusionsUnplanned rehospitalizations were common after LAAC and had similar frequency for patients with vs without previous ischemic stroke and/or TIA. Female sex and index hospitalization LOS > 1 day were among the strongest factors that were independently associated with readmission within 30 days.

Complications and Outcomes of Impella Treatment in Cardiogenic Shock Patients With and Without Acute Myocardial Infarction.

Background In patients with cardiogenic shock (CS), acute myocardial infarction (AMI) is the most common cause, and a percutaneous microaxial ventricular assist device (Impella, Abiomed, Danvers, MA) is a choice for temporary mechanical circulatory support. However, data are limited on complications and outcomes of Impella treatment in patients with CS with and without AMI. Methods and Results Using nationwide prospective registry data in Japan, we included a total of 2047 patients with CS in whom the Impella devices were successfully placed between February 2020 and December 2021. Patients were divided into 2 groups according to the primary indication for the Impella use: AMI versus non-AMI. The primary end point was a composite of in-hospital all-cause death and major complications. Of the 2047 patients, the Impella was indicated for AMI in 1337 (65.3%). In the group without AMI, myocarditis was the leading cause of CS. Patients with AMI-CS were older and more likely to have cardiovascular risk factors than those with non-AMI-CS. The rates of in-hospital mortality (46.0% versus 43.9%, P=0.38) and major complications (35.2% versus 34.7%, P=0.85) were similar between the 2 groups. Overall, multivariable analysis identified older age, higher body mass index, previous transient ischemic attack or stroke, out-of-hospital cardiac arrest, and the Impella 5.0 as factors significantly associated with the primary end point. Conclusions The use of Impella in patients with and without AMI was related to similar clinical outcomes with high mortality and complication rates. Further studies are needed to identify patients who may benefit from the Impella devices in CS. Registration URL: https://www.umin.ac.jp/english. Identifier: UMIN000033603.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: Insights from the Virtual-SAFARI study

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients undergoing atrial fibrillation (AF) ablation. Currently, it remains unclear whether all AF patients should be systematically screened for SDB, or whether pre-selection of patients requiring screening can be improved. We aimed 1) to assess the accuracy of the STOP-Bang screening questionnaire as a tool for detecting SDB in patients scheduled for AF ablation; and 2) to develop a refined, AF-specific version of the STOP-Bang to improve pre-selection. Methods Consecutive patients scheduled for AF ablation without a previous history of SDB and/or SDB screening were included. Patients were digitally referred to the previously described Virtual-SAFARI SDB screening and management pathway1 including a home sleep test using polygraphy. An apnoea-hypopnoea-index (AHI) of ≥15 was interpreted as moderate-to-severe SDB. The accuracy of the STOP-Bang questionnaire (Snoring, Tiredness, Observed apneas, blood Pressure, BMI ≥35 kg/m², Age, Neck circumference, and Gender) was evaluated. Logistic regression was used to assess characteristics within and outside the STOP-Bang questionnaire associated with moderate-to-severe SDB. These characteristics were used to refine the STOP-Bang specifically for AF patients. Results Of 206 included patients, 51% was diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (0.573-0.721). AF-specific refinement of the STOP-BANG resulted in the BOSS-GAP score. Therein, tiredness and neck circumference were removed, while body mass index with cut-off point ≥27 kg/m² and previous stroke or transient ischaemic attack were added. The BOSS-GAP questionnaire performed better with an AUROC of 0.738 (0.672-0.805) in the overall population. Conclusion The STOP-Bang questionnaire showed limited value when used as a pre-selection tool for SDB screening. The refined, AF-specific BOSS-GAP questionnaire demonstrated slightly improved, but still limited accuracy in identifying AF patients with SDB. Whether questionnaires bring an advantage in pre-selection for SDB screening compared to structural screening in patients with AF, requires further study.

Adherence to a mobile health-based atrial fibrillation screening program: a subanalysis from STROKESTOP I and II

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Stockholm County Council, the Swedish Heart & Lung Foundation Introduction Atrial fibrillation (AF) is associated with an increased risk of stroke, which may be reduced through timely and adequate treatment initiation. Consequently, early detection of AF is important. In a recent European Heart Rhythm Association practical guide on the use of digital devices, systematic screening for AF of those ≥75 years is recommended. Purpose To 1) evaluate adherence and adherence consistency to a handheld electrocardiography (ECG)-based device for AF screening and 2) evaluate factors associated with optimal adherence and adherence consistency. Methods In STROKESTOP I and II, half of the 75- and 76-year old population in up to two regions in Sweden were invited to an AF screening program. Participants without previously known AF and without AF during baseline visit, were asked to perform 30-seconds recordings using a handheld ECG-based device for a period of two weeks twice daily in STROKESTOP I and four times a day in STROKESTOP II. Adherence was defined as the number of recordings performed per number of recordings that were asked from the participant over the entire screening period. Adherence consistency was defined as full screening days, i.e. the number of screening days on which the asked number of recordings was performed. Since baseline date was excluded from analysis, the total screening period consisted of 13 days. Results In total, 6436 participants from STROKESTOP I (3585 females (55.7%)) and 3712 participants from STROKESTOP II (2218 females (59.8%)) were included in the current analysis. Median adherence was 100% [92-100%] and 90% [75-98%] in STROKESTOP I and II, respectively. The median number of full screening days was 12 [11-13] in STROKESTOP I and 8 [3-11] in STROKESTOP II. In STROKESTOP I, female sex, region of inclusion, income in 1st to 3rd quartile and no university or college education were factors independently associated with both optimal adherence and adherence consistency (Figure 1). In addition, no previous stroke or transient ischemic attack and the use of beta blockers were associated with optimal adherence, whereas no diabetes and low alcohol index were associated with optimal adherence consistency. In STROKESTOP II, socioeconomic factors were not available at the time of the current analysis. Other associations (female sex, absence of diabetes) were comparable to STROKESTOP I. Conclusions In this screening program for AF, median adherence was optimal in case of twice daily measurements, and nearly optimal in case of measurements four times a day. Several demographic and socioeconomic factors, as well as low alcohol index and the absence of diabetes and previous stroke were associated with optimal adherence and/or adherence consistency.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: insights from the Virtual-SAFARI study

BackgroundSleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF.AimWe aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection.MethodsConsecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea–hypopnoea index (AHI) of  ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening.ResultsOf 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573–0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672–0.805) in the overall population.ConclusionAF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies.Trial registration numberISOLATION was registered NCT04342312, 13-04-2020.Graphical

Abstract 155: NORAHOME. A Virtual Multimodal Stroke Remote Monitoring Hospitalization Program

Background and Aims: The rising pressure on medical services, highlighted throughout the pandemic, has revealed a need for alternative methods of hospital care. Our objective is to evaluate a home hospitalization virtual multimodal monitoring program (NORAHOME) for patients who have had a previous transient ischemic attack (TIA) or minor stroke, as an efficient strategy compared to Routine Clinical Practice (RCP). Methods: A prospective cohort study of consecutive patients with a suspected TIA or minor stroke evaluated at the emergency room of a tertiary hospital by a neurologist between 1st December 2020 and 1st June 2022, had completed NORAHOME and was compared with a historic control group of patients with a suspected TIA or minor stroke who had completed a conventional hospitalization (RCP) between 1st June and 30th November 2020. Results: 430 patient cases were analyzed, 215 patients in the prospective group were compared with a retrospective cohort of the same number of patients. Mean age 75.21 ± 12.6 years; 54.9% women. In the NORAHOME group we observed a recurrence rate of 2.3% (5 patients) and mortality of 2.8% (6 patients) during the follow up. In the RCP group 6.5% (14 patients) presented recurrence and 7% (15 patients) died. No significant differences were found in the risk of early recurrence, emergency room readmission or functional outcome between the groups. Conclusions: In our series of TIA and minor stroke patients, NORAHOME is a safe strategy compared to RCP. The development and implementation of digital home-hospitalization programs may reduce direct hospital costs by shortening length of stay and reducing hospital readmission. Moreover, the program improves self-assessed health outcomes reported by patients and their experience with the healthcare system compared to the RCP.

Characteristics and outcomes of aortic stenosis patients with and without stroke

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Sia CH was supported by the National University of Singapore Yong Loo Lin School of Medicine’s Junior Academic Faculty Scheme Background Aortic stenosis (AS) is related to several atherosclerosis risk factors and is associated with an increased risk of ischaemic stroke. Some reports suggest that aortic valve calcification may predispose to embolic stroke although this is not well-studied. The literature is also sparse regarding individual stroke subtypes and predictors of stroke in AS. Purpose We aimed to 1) Describe rates of ischaemic stroke in AS including specific stroke subtypes; 2) Compare clinical and echocardiographic characteristics of patients with AS who subsequently developed ischaemic stroke versus those who did not, and 3) Identify independent variables associated with subsequent stroke in AS. Methods Patients with AS were recruited from an echocardiography database from September 2011 to December 2015 at a single tertiary centre. The primary study endpoint was acute ischaemic stroke. Clinical characteristics and echocardiographic parameters were compared between patients who suffered a stroke after AS diagnosis and those who did not. Multivariable Cox regression analysis was used to identify factors associated with subsequent stroke. Results A total of 703 patients with AS were studied, with a median follow-up duration of 3.0 (IQR 0.5, 5.0) years. Twenty-two patients (3.1%) developed stroke following AS diagnosis (large vessel, 18.2%; cardioembolic, 50.0%; small vessel, 18.2%; other determined ischaemic stroke, 13.6%). These patients had a greater prevalence of previous stroke or transient ischaemic attack (TIA) (50.0%) compared to patients who did not develop subsequent stroke (20.9%), p<0.001. Patients with AS who developed subsequent stroke also more commonly had atrial fibrillation at the time of indexed echocardiography (40.0%) compared to their counterparts who did not develop stroke (13.5%), p=0.004 (Table 1). Other cardiovascular risk factors and traditional echocardiographic parameters of AS severity were similar between the 2 groups. Degenerative calcified aortic valve was not associated with the development of all types of ischaemic stroke or cardioembolic stroke. AS severity was also not associated with development of stroke. Multivariable Cox regression analysis found previous stroke or TIA (HR 8.00, 95% CI 2.70–23.58, p<0.001) and atrial fibrillation at time of echocardiography (HR 8.81, 95% CI 1.34–10.80, p=0.012) to be independent predictors of subsequent stroke in AS. The key findings of our study are summarised in Figure 1. Conclusions Cardioembolic stroke is the most common stroke subtype in patients with AS. Previous history of stroke or TIA and atrial fibrillation at time of diagnostic echocardiography are independent predictors of subsequent stroke in AS. Calcified aortic valve was not found to be a risk factor for all types of ischaemic stroke or cardioembolic stroke.

Towards an integrated blood pressure self-monitoring solution for stroke/TIA in Ireland: a mixed methods feasibility study for the TASMIN5S IRL randomised controlled trial

BackgroundOptimising blood pressure (BP) control is one of the most important modifiable risk factors in preventing subsequent stroke where the risk increases by one-third for every 10 mmHg rise in systolic BP. This study evaluated the feasibility and potential effectiveness of blood pressure self-monitoring with planned medication titration, to inform a definitive trial of the intervention, in patients with a previous stroke or transient ischaemic attack (TIA).MethodsPatients with a history of stroke/TIA and sub-optimal BP control were invited to take part in a mixed methods feasibility study for a randomised controlled trial. Those meeting the inclusion criteria with systolic BP >130 mmHg were randomised to a self-monitoring intervention group or usual care group. The intervention involved self-monitoring BP twice a day for 3 days within a 7-day period, every month, following text message reminders. Treatment escalation, based on a pre-agreed plan by the general practitioner (GP) and patient, was initiated according to the results of these readings. Semi-structured interviews were carried out with patients and clinicians and analysed thematically.ResultsOf those identified, 47% (32/68) attended for assessment. Of those assessed, 15 were eligible for recruitment and were consented and randomised to the intervention or control group on a 2:1 basis. Of those randomised, 93% (14/15) completed the study and there were no adverse events. Systolic BP was lower in the intervention group at 3 months. Participants found the intervention acceptable and easy to use. GPs found it easy to incorporate into their practice activity without increasing workload.ConclusionsTASMIN5S, an integrated blood pressure self-monitoring intervention in patients with a previous stroke/TIA, is feasible and safe to deliver in primary care. A pre-agreed three-step medication titration plan was easily implemented, increased patient involvement in their care, and had no adverse effects. This feasibility study provides important information to inform a definitive trial to determine the potential effectiveness of the intervention in patients post-stroke or TIA.Trial registrationISRCTN57946500. Registered on 12/08/2019.

High posterior cerebral artery flow predicts ischemia recurrence in patients with internal carotid artery occlusion.

Recurrent stroke is a dreaded complication of symptomatic internal carotid artery occlusion (ICAO). Transcranial Duplex (TCD)-derived increased flow velocity in the ipsilateral posterior cerebral artery (PCA)-P2 segment indicates activated leptomeningeal collateral recruitment and hemodynamic impairment. Leptomeningeal collaterals are pial vascular connections between the anterior and posterior vascular territories. These secondary collateral routes are activated when primary collaterals via the Circle of Willis are insufficient. Our goal was to test the TCD parameter PCA-P2 flow for prediction of ipsilateral ischemia recurrence. We retrospectively analyzed clinical and ultrasound parameters in patients with ICAO. Together with clinical variables, we tested systolic PCA-P2 flow velocity as predictor of a recurrent ischemic event using logistic regression models. Of 111 patients, 13 showed a recurrent ischemic event within the same vascular territory. Increased flow in the ipsilateral PCA-P2 on transcranial ultrasound (median and interquartile range [IQR]: 60 cm/s [IQR 26] vs. 86 cm/s [IQR 41], p = <0.001), as well as previous transient ischemic attack (TIA) and low NIHSS were associated with ischemia recurrence. Combined into one model, accuracy of these parameters to predict recurrent ischemia was 89.2%. Our data suggest that in patients with symptomatic ICAO, flow increases in the ipsilateral PCA-P2 suggest intensified compensatory efforts when other collaterals are insufficient. Together with the clinical variables, this non-invasive and easily assessable duplex parameter detects ICAO patients at particular risk of recurrent ischemia.

S-10-6: BLOOD PRESSURE TARGETS FOR SECONDARY PREVENTION OF STROKE

The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) showed the benefits of blood pressure (BP) lowering for secondary stroke prevention in stroke survivors for the first time after a long dispute in the last century and triggered active hypertensive therapy for stroke patients globally in this century. A post hoc analysis of PROGRESS demonstrated that both the lowest risks of ischemic stroke and of hemorrhagic stroke were among the one-quarter of patients with the lowest achieved follow-up BP levels (median 112/72 mmHg), and that these risks increased progressively with higher follow-up BP levels in the large cohort of patients with previous stroke or transient ischemic attack. A similar tendency for an increased risk of ischemic/hemorrhagic stroke by higher follow-up BP levels was reproduced in subsequent stroke trials. Several trials sought to clarify the preventive effect against recurrent stroke by randomizing patients into two groups with different BP lowering targets. In patients with recent lacunar stroke in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, lowering systolic BP to &lt; 130 mmHg significantly reduced the risk of intracerebral hemorrhage (ICH) by 63% and insignificantly reduced the risk of ischemic stroke by 16% compared to lowering to 130–149 mmHg. The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study, involving patients having a history of stroke within the previous 3 years showed similar results: lowering BP to &lt; 120/80 mmHg, relative to &lt; 140/90 mmHg, reduced the risk of ICH by 91% and that of ischemic stroke by only 9%. These trials failed to demonstrate a significant reduction in the risk of any stroke as the primary outcome by intensive BP lowering, since the incidence of ischemic stroke was much higher than that of ICH for both trials. A meta-analysis of these two trials and two more small studies finally succeeded in showing a statistically significant 22% reduced risk for any stroke recurrence by lowering systolic BP to at least &lt; 130 mmHg. The current guidelines recommend systolic BP control aiming at &lt; 130 mmHg or 120–130 mmHg for adults who experience ischemic stroke. RESPECT is epochal as the first large population trial to examine the importance of systolic BP lowering to &lt; 120 mmHg. Such strict control would undoubtedly decrease incidental ICH, especially for patients taking antithrombotic agents. However, the necessity of strict BP control for protection of brain tissues from ischemic injury is still an unresolved matter that needs to be addressed in future studies.

HATCH Score for Predicting Mortality in COVID-19 Patients.

We aimed to evaluate the relationship between HATCH score [hypertension, age >75 yr, previous transient ischemic attack (TIA) or stroke (doubled), chronic obstructive pulmonary disease, heart failure (doubled)] and in-hospital mortality in COVID-19 patients. Overall, 572 COVID-19 patients hospitalized between Mar 15 and Apr 15, 2020, were included in this multicenter retrospective study, in Turkey. The HATCH score of each patient was calculated. Mortality results were followed for 50 days. The patients were divided into 2 groups developing mortality (n=267) and non-mortality (n=305). Clinical outcomes were defined as in-hospital mortality improvement status. HATCH scores in non-survivors of COVID-19 were significantly higher than in survivors (P<0.001). In logistic regression analysis, HATCH score (OR: 1.253, 95% CI: 1.003-1.565; P=0.047), platelet count (OR: 0.995, 95% CI: 0.993-0.998; P<0.001), C-reactive protein level (OR: 1.010, 95% CI: 1.007-1.013, P<0.001) and estimated glomerular filtration ratio (eGFR) level (OR: 0.963, 95% CI: 0.953-0.973; P<0.001) were independent predictors of in-hospital mortality in COVID-19 patients. The HATCH score is useful in predicting in-hospital mortality in patients hospitalized with COVID-19.

272 A SUDDENLY RIGHT-TO-LEFT SHUNT: THE IMPORTANCE OF EVALUATING PATENT FORAMEN OVALE DURING CARDIOPULMONARY EXERCISE TESTING

Abstract A 55-years-old male affected by heart failure with reduced ejection fraction (HFrEF) was accepted into the Cardiology Department for increasing dyspnea during the last few months. He previously underwent implantation of a biventricular implantable cardioverter defibrillator (ICD) in primary prevention. Medical history included healthy coronary vessels at invasive coronary angiography and an episode of transient ischemic attack (TIA). The patient was referred to our center to evaluate the dyspnea components and to establish an etiology for the novel onset of left ventricular impairment. He underwent a left-right catheterization that did confirm the absence of obstructive coronary disease and signs of pulmonary hypertension (PH) at rest. The transthoracic echocardiogram showed a dilated left ventricle and global hypokinesia (LVEF of 35%). During the stay, the therapy was further optimized according to the latest European guidelines. Before discharge, in order to better assess the dyspnea and the limited tolerance to exercise, a cardiopulmonary exercise testing (CPET) was performed. CPET showed that the VO2 peak was severely reduced compared to the predicted value (16.8 ml/kg/min, corresponding to 51% of the predicted). After 6 minutes of exercise, at around 60 WR, a considerable increase in PETO2 and RER with a concomitant decrease in PETCO2 and a slight oxygen desaturation were observed. Also, a deep increase in VE/VCO2 slope was seen, underlying an exercise-induced pulmonary hypertension. In the suspicion of an inter-atrial shunt, a subsequent rest transthoracic echocardiogram with a bubble test was performed, demonstrating the presence of a patent foramen ovale (PFO). Discussion The foramen ovale is a vestigial communication between the atria that works as a bypass of the pulmonary circulation during fetal life and then seals at birth after the start of breathing in most people. In around 25% of adults, patency of foramen ovale persists and, in some cases, can lead to a source of a right-to-left shunt, particularly in patients with heart failure that can experience PH at rest or during exercise. This may allow a mixture of oxygenated and non-oxygenated blood that affects pulmonary gas exchange efficiency and may allow blood clots formed in the right circulation to embolize into the left circulation. From a pathophysiological point of view, a right-to-left passage of deoxygenated blood induces the activation of chemoreceptors which induce hyperventilation to adequately compensate for the high amount of CO2 in blood from the right sections of the heart. In people not experiencing pulmonary pressure increase during exercise, right-to-left shunt via a PFO is very unlikely since left atrial pressure is higher than right atrial pressure. However, in the presence of PH, right atrial pressure can overcome left atrial pressure and force venous blood through the defect directly into the systemic circulation. The concomitant increase in VE/VCO2 slope underlines exercise-induced PH, which is frequently associated with heart failure and further contributes to exercise intolerance. Conclusions In the presented case, CPET helped diagnose a misunderstood PFO with a right-to-left shunt induced by effort in a patient with a previous TIA. This observation demonstrates that it could be helpful to identify this eventuality during exercise, to discern patients with higher risk of cardiovascular events who would benefit from a percutaneous closure.

Specific clinical vignettes in high-risk protected percutaneous coronary intervention.

There are several cardiac- and patient-related factors that come into play when considering patients for protected percutaneous coronary intervention (PCI). Cardiac factors include complexity/location of coronary lesions, the degree of left or right ventricular impairment, the presence of valvular lesions, and ventricular arrhythmias. Patient related factors include comorbidities that would render the patient at a higher risk of death should cardiogenic shock ensue during the procedure. Comorbidities include chronic lung disease (chronic obstructive airways disease, asthma, pulmonary fibrosis), renal or liver impairment, other cardiovascular diseases (such as previous cerebrovascular accident or transient ischemic attack, peripheral arterial disease, carotid stenosis), diabetes, frailty and advanced age. Here, we present three very different cases where left ventricular support was deemed appropriate to reduce peri-procedural risk and optimize outcomes.

Outcomes with IV tenecteplase and IV alteplase for acute ischemic stroke with or without thrombectomy in real-world settings in the United States

Background and PurposeAlthough many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. Materials and MethodsWe analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. ResultsAmong 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p<0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p<0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. ConclusionsIn an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.

Residual stroke risk despite oral anticoagulation in patients with atrial fibrillation.

Oral anticoagulation (OAC) reduces the risk of thromboembolic events in patients with atrial fibrillation (AF); however, thromboembolism (TE) still can occur despite OAC. Factors associated with residual risk for stroke, systemic embolism, or transient ischemic attack events despite OAC have not been well described. The purpose of this study was to evaluate the residual risk of thromboembolic events in patients with AF despite OAC. A total of 18,955 patients were analyzed in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I and II) using multivariable Cox proportional hazard modeling. Mean age was 72 ± 10.7, and 42% were women. There were 451 outcome events. The risk of TE despite OAC increased with CHA2DS2-VASc score: 0.76 (95% confidence interval [CI] 0.63-0.92) events per 100 patient-years for CHA2DS2-VASc score <4 vs 2.01 (95% CI 1.81-2.24) events per 100-patient years for CHA2DS2-VASc score >4. Factors associated with increased risk were previous stroke or transient ischemic attack (hazard ratio [HR] 2.87; 95% CI 2.30-3.59; P <.001), female sex (HR 1.52; 95% CI 1.24-1.86; P <.001), hypertension (HR 1.50; 95% CI 1.09-2.06; P = .01), and permanent AF (HR 1.47; 95% CI 1.12-1.94; P = .001). When transient ischemic attack was excluded, the results were similar, but permanent AF was no longer significantly associated with thromboembolic events. Patients with AF have a residual risk of TE with increasing CHA2DS2-VASc score despite OAC. Key risk markers include previous stroke/transient ischemic attack, female sex, hypertension, and permanent AF.