Rate Of Stroke In Patients Research Articles

Mechanical Aortic Valve Prostheses Offer a Survival Benefit Over Bioprostheses Among 50 to 65-Year-Olds: The AUTHEARTVISIT Study

Background: The present study investigated long-term mortality after aortic valve replacement (AVR) with bioprosthetic (B) or mechanical aortic valve prostheses (M) in a European social welfare state. Methods: We analysed patient data from health insurance records covering 98% of the Austrian population between 2010 and 2018. Subsequent patient-level record linkage with national health data provided patient characteristics and clinical outcomes. Further reoperation, myocardial infarction, heart failure, and stroke were evaluated as secondary outcomes. Findings: A total of 13 993 patients were analysed and the following age groups were examined separately: 65 years (10 654 patients: 1·26% M, 98·74% B). Multivariable Cox regression revealed that the use of B-AVR was significantly associated with higher mortality in patients aged 50 – 65 years compared to M-AVR (HR = 1·676 [1·289 – 2·181], p < 0·001). B-AVR also performed worse in a competing risk analysis regarding reoperation (HR = 3·483 [1·445 – 8·396], p = 0·005) and myocardial infarction (HR = 2·868 [1·255 – 6·555], p = 0·012). However, the risk of developing heart failure and stroke did not differ significantly after B-AVR and M-AVR in any age group. Interpretation: Patients aged 50 – 65 years who undergo M-AVR had better long-term survival, and a lower risk of reoperation and myocardial infarction, compared to B-AVR. Even though anticoagulation is crucial in patients with M-AVR, we did not observe significantly increased stroke rates in patients with M-AVR. This evident survival benefit in recipients of mechanical aortic valve prostheses aged < 65 years critically questions current guideline recommendations. Clinical Trial Registration Details: The trial was registered at clinicaltrials.gov (NCT: NCT04900909). Funding Information: This work was supported by the institutional research laboratories ARGE Ankersmit (FOLAB Chirurgie). Declaration of Interests: All other authors report no competing interests. Ethics Approval Statement: This study was a nationwide, population-based cohort study and complied with the Declaration of Helsinki. It was approved by the ethics committee of lower Austria (EC number: GS1-EK-4/722-2021).

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

BackgroundStroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR). ObjectivesThe purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization. MethodsData from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]). ResultsA total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47). ConclusionsStroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.

Abstract P289: Gender Differences in Rates of Stroke in Patients With Hypertrophic Obstructive Cardiomyopathy With and Without Atrial Fibrillation

Introduction: Stroke is a known complication of hypertrophic obstructive cardiomyopathy (HOCM) and this complication is more common in patients with accompanying atrial fibrillation (AF). However, data regarding gender related differences with respect to this complication is sparse. Objective: We sought to understand the gender differences in rates of stroke in patients with HOCM with and without AF. Methods: The Nationwide Inpatient Sample was queried from 2010 to 2014 using ICD-9 codes 425.1 and 425.11 for HOCM in all diagnosis fields. AF was identified by ICD-9 code 427.31. We excluded patients with an indicator for transfer to another acute-care facility to reduce the possibility of data duplication. Chi-square was used for statistical analysis. Results: From 2010 to 2014, we identified 73,347 patients with HOCM (Mean age 63.76 ± 16.5 years; females 59% and Caucasians 67.5%). The overall rate of ischemic stroke in this cohort was 2153 (2.9%). Rate of ischemic stroke between males and females was similar (2.9% vs 3%; p &lt;0.001). AF was present in 26,393 (36%), male vs female (39.4% vs 33.7%; p &lt;0.001). Overall, prevalence of stroke in HOCM patients with and without AF was significant 3.5% vs 2.6%; p&lt;0.001. Between males and females, the rates of stroke in HOCM patients with and without AF were not different (3.5% vs 3.5%, p =0.4 and 2.4% vs 2.7%; p =0.9). Conclusion: Although stroke rates were higher in HOCM patients with AF, stroke rates were similar in both genders of HOCM patients with and without AF. It is important to consider anticoagulation in these patients to reduce the risk of stroke.

Ефективність противірусної терапії у вторинній профілактиці ішемічного інсульту на тлі маніфестації вірусної інфекції

Recurrent stroke remains the key health issue in the world. A higher three-year recurrence rate of stroke in patients with persistence of the genome of herpes viruses, and with presence in the blood of the genome of at least 2 types of viruses was identified. These investigations demonstrate the importance of further research into the role of antiviral therapy in improving the rehabilitation and secondary prevention of stroke in patients with persistent viral infection The purpose of the study was to evaluate the effectiveness of antiviral therapy in the secondary ischemic stroke prevention on the viral infection manifestation background. Material and methods. The study included 105 patients with moderate to severe ischemic stroke with a viral manifestation confirmed by the detection of herpes virus’s DNA (HSV1, HSV2, EBV, CMV, HHV6) and Flu RNA. Patients who were additionally prescribed antiviral drugs on the background of traditional therapy were in the main group (n = 35). Patients who received only traditional, recommended by the modern stroke treatment guidelines, therapy and secondary stroke prevention measures were included in the comparison group (n = 70). Results and discussion. We found that the effectiveness of the proposed preventive treatment depended on the viral load of the patient. In the presence of three or more types of viruses, the proposed therapy provided a significantly lower ischemic stroke recurrence rate, compared to the patients who did not receive antiviral therapy 11.1% vs. 49.8%, p = 0.042. Prevention of recurrent ischemic stroke, which should have started as soon as possible after the development of the first stroke or transient ischemic attack occurrence, F. Rincon and R. L. Sacco (2008) consider the most relevant in this group of patients. Herewith, as emphasized by D. G. Hackam and J. D. Spence (2007), comprehensive prevention has reduced the risk of recurrent ischemic stroke by almost 80%, thus preventing 4 out of 5 possible disorders. However, both native and world literature still has a lack of systematic data of the problem of antiviral therapy using in patients with acute disorders of cerebral circulation, although it has been proven that infectious and inflammatory complications are an important pathogenetic factor of its unfavorable and severe outcome. M. S. Elkind et al. (2016) consider that antiviral drugs such as acyclovir may play an appropriate role in the prevention of recurrent ischemic stroke in children if their causal relation is confirmed. Conclusion. The use of acyclovir in complex rehabilitation therapy and secondary stroke prevention in patients with viral infection manifestation provided an increase in the average score of Bartel index after 1 year, p = 0.017. In the case of antiviral therapy using in the complex prevention of recurrent vascular events in patients with viral infection manifestation, the three-year recurrence rate of stroke is lower (p = 0.042)

Save your brain – does the sentinel cerebral protection device work?

Abstract Background Transcatheter aortic valve implantation (TAVI) is increasingly used for the treatment of severe symptomatic aortic stenosis (AS), also in low-risk patients. Periprocedural embolic stroke is rare, but potentially associated with considerable morbidity and mortality. Thus, there is great interest in preventing any cerebral embolic event. At present, only one cerebral embolic protection systems (CPS) is commercially available and little is known about its efficacy in preventing stroke during TAVI. The Sentinel CPS is a FDA-approved system consisting of two inter-connected filters that are placed in the brachiocephalic trunk and the left carotid artery via the right radial artery. Material and methods Consecutive patients undergoing TAVI between 11/2018 and 11/2019 were enrolled. Consecutive patients treated by one operator received the Sentinel device, if anatomically possible. Periprocedural stroke rate, as defined by VARC2-criteria, and mortality up to 7 days after procedure was assessed. Descriptive statistics was performed to identify baseline variables associated with elevated risk of stroke and Cox-regression analysis was used to investigate its influence on outcome. Results 268 patients (47.4% female, 81±7 years) were included. In 74 patients (27.6%), a Sentinel CPS was used, in 63 (23.5%) it was positioned correctly in the brachiocephalic trunk and left carotid artery. Only these patients were considered Sentinel-protected. Patients with and without Sentinel presented with similar baseline characteristics with regard to age (no CPS vs CPS; 80.3 vs 81.5 years; p=0.233), sex (female 47.3% vs 47.7%; p=0.967), previous stroke (6.9% vs 3.2%; p=0.373), peripheral artery disease (9.8% vs 4.8%; p=0.305), coronary artery disease (63.1% vs 57.1%; p=0.370), and kidney function (GFR 52 vs 56 ml/min/m2; p=0.283). The EuroScore II (6% vs 6%; p=0.937), periprocedural predilation (48.3% vs 47.6; p=0.925), postdilation (29.3% vs 31.7%; p=0.707) and procedure time (59min vs 66min; p=0.152) were not different. In total, 15 strokes (5.6%) occurred, of which 9 (3.3%) were disabling strokes as defined by the VARC2-criteria. In Sentinel-protected patients undergoing TAVI, no periprocedural stroke was observed (no CPS 7.3% vs 0.0%; p=0.026). Conclusion Our results suggest that Sentinel CPS significantly reduces periprocedural stroke rates in patients undergoing TAVI compared to patients without CPS. However, the study population is small and randomized trials are still needed. Funding Acknowledgement Type of funding source: None

Point-of-care testing of coagulation in patients treated with edoxaban

Edoxaban, alongside other direct oral anticoagulants (DOAC), is increasingly used for prevention of thromboembolism, including stroke. Despite DOAC therapy, however, annual stroke rate in patients with atrial fibrillation remains 1–2%. Rapid exclusion of relevant anticoagulation is necessary to guide thrombolysis or reversal therapy but, so far, no data exists on the effect of edoxaban on available point-of-care test systems (POCT). To complete our previous investigation on global coagulation-POCT for the detection of DOAC, we evaluated whether CoaguChek®-INR (CC-INR) is capable of safely ruling out edoxaban concentrations above the current treatment thresholds of 30/50 ng/mL in a blood sample. We studied patients receiving a first dose of edoxaban; excluding subjects receiving other anticoagulants. Six blood samples were collected from each patient: before drug intake, 0.5, 1, 2 and 8 h after intake, and at trough (24 h). CC-INR and mass spectrometry for edoxaban concentrations were performed for each time-point. One hundred and twenty blood samples from 20 patients contained 0–302 ng/mL of edoxaban. CC-INR ranged from 0.9 to 2.3. Pearson’s correlation coefficient showed strong correlation between CC-INR and edoxaban concentrations (r = 0.73, p < 0.001). Edoxaban concentrations > 30 and > 50 ng/mL were ruled out by CC-INR ≤ 1.0 and ≤ 1.1, respectively, with high specificity (> 95%), and a sensitivity of 44% (95%-confidence interval: 30–59%) and 86% (74–93%), respectively. Our study represents the first evaluation of coagulation-POCT in edoxaban-treated patients. CC-POCT is suitable to safely exclude clinically relevant edoxaban concentrations prior to thrombolysis, or guide reversal therapy in stroke patients.

Intracorporeal VAD Outcomes in the ACTION Quality Improvement Network

The initial project of ACTION (Advanced Cardiac Therapies Improving Outcomes Network) is focused on improving stroke rates in patients implanted with a ventricular assist devices (VAD) in participating centers. The initial interventions targeted improving communication, anticoagulation, and blood pressure management. We sought to describe the characteristics and outcomes of patients implanted with intracorporeal, continuous flow VADs (cfVAD). The ACTION registry was used to determine the stroke frequency in cfVAD implanted patients between April 2018 and September 2019, the time from development of the quality improvement bundle to the present. Sixty two patients (33 Heartmate3 [HM3] and 29 Heartware [HVAD]) were identified (Table). The majority had dilated cardiomyopathy (76%). Of the 12 (20%) patients with congenital heart disease (CHD), 9 (75%) had single ventricle (SV) physiology. The HM3 patients were older (16.5 yr vs 12.8 yr) and larger (64.2 kg vs 51.9 kg) than the HVAD patients. No significant difference was observed in diagnosis, duration of support, device strategy, or clinical outcome. One patient (2%) experienced a stroke during 6,920 days of support. Forty of the 45 (89%) patients to reach a clinical endpoint experienced a positive outcome (transplant or explant for recovery) while 17 (27%) patients remain on device. The stroke rate is low and survival good among patients implanted with an intracorporeal cfVAD at ACTION centers using the clinical protocols developed within the network. The HVAD is currently being used more frequently in younger and smaller patients. There has been an appreciable increase in the number and frequency of implants in patients with CHD, especially SV disease, as compared to previous reports. Future efforts within ACTION will focus on improving clinical outcomes as devices are increasingly used at individual centers and as the number of VAD-supported patients with congenital heart disease continues to grow.

The correlation between recurrent risk and CYP2C19 gene polymorphisms in patients with ischemic stroke treated with clopidogrel for prevention.

Background:To explore the correlation between recurrent risk and CYP2C19 gene polymorphisms in patients with ischemic stroke (IS) treated with clopidogrel for prevention.Methods:A total of 289 patients with IS treated with clopidogrel regularly were enrolled in this study, and stroke recurrence of all patients were recorded by follow-up. The correlation between CYP2C19 gene polymorphism and stroke recurrence in patients taking clopidogrel regularly was analyzed.Results:After a mean follow-up period of 6 months, there were 289 patients who took clopidogrel regularly, and 41 of which occurred recurrent stroke. Patients of poor metabolizer and intermediate metabolizer had higher risk of recurrent stroke comparing with patients of extensive metabolize, and the odds ratios were 2.88 (95% confidence interval [CI] 1.31–6.33, P = .068) and 3.00 (95% CI 1.09–8.22, P = .027), respectively. The recurrence risk of ∗2 (G681A)A allele carriers was 3.30 times that of G allele carriers (P = .0065). The recurrence rate of stroke in patients carrying heterozygous and homozygous ∗2 allele mutant was 1.96 times (P = .071) and 3.30 times (P = .012) that of patients with wild-type genes. Multifactor logistic regression analysis result indicated carrying loss of function (LOF) allele was an independent risk factor of stroke recurrence.Conclusion:For patients with IS treated with clopidogrel regularly for secondary prevention, poor metabolizer, and intermediate metabolizer patients had higher risk of recurrent stroke comparing with extensive metabolize ones. Carrying CYP2C19 LOF allele is an independent risk factor of stroke recurrence in patients with IS.

STROKE RISK IN PATIENTS WITH PAROXYSMAL AND PERSISTENT ATRIAL FIBRILLATION TREATED WITH ANTI-ARRHYTHMIC DRUGS VS. CATHETER ABLATION

Atrial fibrillation (AF) promotes thrombus formation in the left atrium and thus increases the risk of stroke. We sought to compare the rate of thromboembolic (TE) events in AF patients receiving catheter ablation with published stroke rate in patients treated with anti-arrhythmic drugs (AAD). A

Abstract 83: Encephaloduroarteriosynangiosis Surgery Averts Stroke in Atherosclerotic Patients With Border-Zone Stroke

Introduction: Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke around the world. Among patients with ICAD being treated with Intensive Medical Management (IMM), those who initially present with ischemia in border-zone areas have the highest recurrence rates (37% at one year) due to association with poor collaterals. Methods: We recently concluded a phase II clinical trial of EDAS revascularization for patients with symptomatic ICAD failing medical management (ERSIAS). EDAS creates new collaterals from the donor branches of the external carotid artery. We performed an analysis of ERSIAS patients who had stroke as qualifying event and ischemia of a border-zone area on their initial MRI. We compared their outcomes to the subgroup of patients with border-zone ischemia from SAMMPRIS. Results: Of 52 patients included in the ERSIAS trial, 35 patients presented with strokes at baseline and 28 had border-zone pattern, including 15 (54%) with exclusive border-zone ischemia and 13 (46%) with mixed patterns including the border-zone. Of these 28 patients with border zone strokes as qualifying event, three (11%) presented recurrent strokes up to one year after EDAS surgery. When compared with the matched population from the medical arm of SAMMPRIS, EDAS patients had significantly lower than expected rate of recurrence (11% vs. 37% p=0.02, OR:0.21, 95%CI= 0.05-0.84), representing an absolute risk reduction of 26%. Conclusion: When compared with matched controls on IMM, EDAS reduced the expected rate of recurrent stroke in patients at the highest risk of recurrence. This supports the concept that EDAS might avert strokes due to hypoperfusion by generating new collaterals to ischemic cerebral territories and could supplement IMM in patients with border-zone infarctions due to ICAD.

Retinal artery occlusion does not portend an increased risk of stroke

ObjectiveThe aim of this study was to determine the subsequent risk of stroke after a diagnosis of retinal artery occlusion (RAO). We hypothesized that the risk would be low and comparable to that of the general population. RAO is relatively rare and often incorrectly diagnosed. We believe our institution is in a unique position to investigate this relationship with both a high-volume eye center and vascular laboratory. MethodsThis was a retrospective, single-institution review of 221 patients diagnosed with RAO from 2004 to 2018, confirmed with fluorescein angiography. Demographics, comorbidities, imaging of the carotid arteries, and prospective events, such as stroke, myocardial infarction (MI), and death, were recorded. Time to first stroke, first MI, and death was estimated using Kaplan-Meier estimation separately and as a composite end point. ResultsThere were 221 patients identified with a confirmed diagnosis of RAO. The mean age in the cohort was 66.1 years; 53% of patients were male, and 29% were diabetic. Median length of follow-up was 2.2 years. Five patients (2.3%) had a documented stroke; four of the five strokes occurred at the time of RAO, with one that was contralateral occurring at 1.2 years. There were eight MIs (3.6%) in the cohort, two of which resulted in death. Twenty-two patients (10%) experienced a stroke, MI, or death. There were 141 (63.8%) patients who had carotid imaging performed, of whom 20 (14.2%) were found to have >50% stenosis. ConclusionsThe rate of stroke in patients with confirmed RAO was 2.3%; however, excluding concurrent ischemic events, the risk was <1%. The incidence of carotid artery stenosis >50% was 14.2%. The authors conclude that the risk of stroke after confirmed RAO is lower than previously reported and comparable to prior population-based studies of all at-risk adults.

Management of Asymptomatic Carotid Artery Stenosis.

The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis. Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.

CAR 7. Duration of Blood Flow Reversal During Transcarotid Artery Revascularization Does Not Affect Outcome

Transcarotid artery revascularization (TCAR) has become an increasingly popular alternative to carotid endarterectomy and transfemoral carotid stenting. TCAR uses carotid blood flow reversal through a proprietary ex vivo common carotid artery to femoral vein shunt for neuroprotection during the placement and angioplasty of the carotid stent. Operators typically try to keep flow reversal time (FRT) as short as possible to avoid neurologic complications despite a lack of data demonstrating any adverse effect. We analyzed the relationship between TCAR FRT and major adverse events. There were 307 patients who underwent TCAR at four high-volume institutions. We separated the patients into groups on the basis of FRT, defined as short (3-7 minutes; group I), medium (8-12 minutes; group II), and long (>12 minutes; group III) FRT. A subset of group III patients with FRT ≥20 minutes was defined as the very long group (group IV). Stroke, myocardial infarction, and death rates at 30 days were collected in all patients and were compared between groups using χ2 analysis. There were four strokes in the total cohort, yielding an overall stroke rate of 1.3%. All strokes were minor in nature (two ipsilateral, two contralateral), and all patients had full recovery within 30 days. We found no significant difference in the stroke rate between any of the FRT groups (P = .73; Table). Even patients who had very long FRT ≥20 minutes also had no increased rate of stroke (0/24 [0.0%] vs 4/283 [1.4%]; P > .99). The four strokes occurred in patients with FRT of 6, 7, 11, and 12 minutes. There was also no difference in the composite stroke/death or stroke/death/myocardial infarction rates among groups. FRT does not affect stroke rates in patients undergoing TCAR. Operators should focus on the technical aspects of the procedure during flow reversal rather than on the amount of FRT.TablePostoperative clinical outcomes stratified by flow reversal time (FRT)Group I (3-7 minutes)Group II (8-12 minutes)Group III (13+ minutes)Group IV (≥20 minutes; subset of group III)No.981426724Stroke, 30 days2 (2.0)2 (1.4)0 (0)0 (0)Stroke/death, 30 days2 (2.0)4 (2.8)0 (0)0 (0)Stroke/death/myocardial infarction, 30 days2 (2.0)5 (3.5)0 (0)0 (0)Values are reported as number (%). Open table in a new tab

ROLE OF GLYCEMIC CONTROL ON ISCHEMIC STROKE IN AF

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Diabetes is a known risk factor for thromboembolic events in patients with atrial fibrillation (AF). However there has been so many debates about the effect of glycemic control as a considerable risk factor. We conducted a study to evaluate any relation between A1c values and rate of stroke in patients with both AF and diabetes mellitus (DM). METHODS: This is a retrospective case-control study conducted at a teaching university-based hospital from December 2013 to December 2018. We evaluated inpatients and outpatients with diagnoses of AF and DM or the presence or absence of either a Transient Ischemic Attack (an acute-onset focal and localizable but transient neurological deficit) with or a stroke (an acute-onset focal and localizable neurologic deficit with infarction of an arterial territory on imaging). The HbA1c values were reviewed and propensity matched on CHA2DS2-VASc scores, anticoagulation status and age between study and control groups. Chi-squared test was used to compare categorical variables and t-test to compare continuous variables. RESULTS: Among 233 diabetic patients with AF, we were able to include 197 who had documented A1c values (mean age, 74 years; 69 [35%] women). The study group (n=31) includes DM patients with AF who had stroke. After matching the variables, there was no difference in the CHA2DS2-VASc scores (P = 0.717), the rate of stroke (P = 0.96), and the A1c value (P = 0.19) between two groups. Average A1c values were 7.2 [SD, 1.3] and 7.6 [SD, 1.5] in case and control groups, respectively. There were no differences between the rate of anticoagulation between two groups, prior to the acute event (32.3% in study group vs 36.6% in control group, P = 0.66) CONCLUSIONS: There is no correlation between magnitude of A1c elevation and risk of TIA or stroke in patients with both diabetes mellitus and atrial fibrillation. Limitations included a single-center and a small sample size. Lower Hba1c did not confer less risk of cerebrovascular events. Controlled and uncontrolled diabetics should continue to be scored equally in assessing the risk of stroke. CLINICAL IMPLICATIONS: “High Value Care” and “Choosing Wisely” are the core deciding factor for evidence-based practice among general internists. In this study, we found that the degree of glycemic control may not have a major prognostic role regarding risk of TIA or stroke in AF among patients with DM. It may be worth reevaluating the utility of obtaining A1c values at the time of stroke or TIA. An old saying, “treat the patient and not the number” might be appropriate in this context. DISCLOSURES: No relevant relationships by Ibrahim Ghobrial, source=Web Response No relevant relationships by Navneet Kaur, source=Web Response No relevant relationships by Mehrshid Kiazand, source=Web Response No relevant relationships by Evan Kudron, source=Web Response No relevant relationships by Noor-ul-huda Mehdi, source=Web Response No relevant relationships by Marie Tuft, source=Web Response No relevant relationships by Sowjanya Yenigalla, source=Web Response

Successful COMPASS, Disappointing COMMANDER HF, What Have We Learned From These Two Trials?

Despite considerable progress in the field of heart failure about drugs and device therapy, the mortality rate of patients with heart failure remains high. Studies have shown that thromboembolism and stroke are associated with high mortality in patients with heart failure. Although warfarin therapy reduces the rate of ischemic stroke in patients with heart failure, the overall benefit from warfarin in this population seems to be offset by the increased bleeding risk. Thus, whether patients with chronic heart failure might benefit from anticoagulation, especially in patients with sinus rhythm, is still controversial. Rivaroxaban, a new oral anticoagulant, is a selective direct factor Xa inhibitor that is used to reduce thrombin generation, which may bring hope to anticoagulation in patients with heart failure. However, the COMPASS trial and recently published COMMANDER HF trial presented different results. By carefully analyzing 2 clinical trials, we think several factors might explain this different outcome.

Routine preoperative aortic computed tomography angiography is associated with reduced risk of stroke in coronary artery bypass grafting: a propensity-matched analysis.

The aim of this study was to determine stroke rates in patients who did or did not undergo routine computed tomography angiography (CTA) aortic imaging before isolated coronary artery bypass grafting (CABG). We conducted a retrospective analysis of a prospectively maintained single-centre registry. Between 2009 and 2016, a total of 2320 consecutive patients who underwent isolated CABG at our institution were identified. Propensity score matching was used to create a paired cohort of patients with similar baseline characteristics who did (CTA cohort) or did not (non-CTA cohort) undergo preoperative aortic CTA. The primary end point of the analysis was in-hospital stroke. In 435 propensity score-matched pairs, stroke occurred in 4 patients (0.92%) in the CTA cohort and in 14 patients (3.22%) in the non-CTA cohort (P = 0.017). Routine preoperative aortic CTA was associated with a significantly reduced risk of in-hospital stroke [relative risk 0.29, 95% confidence interval (CI) 0.09-0.86; P = 0.026; absolute risk reduction 2.3%, 95% CI 0.4-4.2; P = 0.017; number needed to treat = 44, 95% CI 24-242]. A preoperative screening for atheromatous aortic disease using CTA is associated with reduced risk of stroke after CABG. The routine use of preoperative aortic CTA could be applied so that surgical manipulation of the ascending aorta can be selectively reduced or avoided in patients with atheromatous aortic disease.

Strokes and Giant cell arteritis: imaging characteristics

Giant cell arteritis (GCA) is associated with an increased risk of cardio- or cerebro-vascular death. The stroke rate in patients with GCA varies between 2.7 and 7.4%. The etiological diagnosis may be challenging between atherosclerotic stroke and stroke related to GCA. Case of an old woman who had ischemic stroke and concomitant diagnosis of GCA and brain imaging characteristics.

Closing the gap on patent foramen ovale and cryptogenic stroke

ABSTRACTIntroduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone.Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy.Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.

Abstract 97: Pre-Existing Anticoagulation Does Not Affect Stroke Rates in Patients With Left Sided Infective Endocarditis

Introduction: Stroke is a devastating and relatively frequent complication of infective endocarditis (IE), especially infection involving left-sided valves. Management of anticoagulation (AC) in left sided IE (LSIE) is controversial as it is unclear whether or not AC impacts stroke risk in this population. Current guidelines are equivocal on their recommendations regarding AC management. The objective of this study was to evaluate the effect of AC on neurologic outcomes in patients with LSIE. Methods: All patients admitted to a tertiary academic hospital in North Carolina, with a diagnosis of left sided IE between December 2011 and April 2018 were identified. Patients were stratified based on the receipt of therapeutic AC. The primary outcome measure was the rate of radiographically confirmed stroke at 10 weeks. Relevant data were analyzed with univariate and multivariate analysis. Results: Two-hundred and fifty-eight consecutive patients with LSIE were identified. Individuals receiving AC (n=50) were older (median age of 63 vs 52, p = 0.02) more likely to have a history of atrial fibrillation (34% vs 5%, p &lt; 0.01), had more prosthetic valve IE (38% vs 10.1%, p &lt;0.01) and had lower incidence of mitral valve IE (40% vs 62%, p &lt; 0.01). There was no significant difference in the rate of stroke, cerebrovascular hemorrhage, or mortality at ten weeks between the two cohorts. Mitral valve involvement (OR 2.20, 95CI 1.25-3.988) and intravenous drug use within 3 months of presentation (OR 2.10, 95CI 1.11-3.95) were identified as independent risk factors for stroke. Conclusions: AC therapy did not appear to have an effect on stroke in patients with LSIE. Furthermore, use of AC did not result in a greater occurrence of cerebrovascular hemorrhage or increased mortality. Continuation of AC in patients with a pre-existing indication should be considered in patients with LSIE in the absence of other contraindications. More robust studies are warranted to substantiate this recommendation.

Risk stratification for stroke in atrial fibrillation: a critique.

Despite the demonstrable success of oral anticoagulants in reducing the rate of stroke in patients with atrial fibrillation, they continue to be seriously underutilized. Indications for their use as stated in the guidelines incorporate a number of risk score algorithms, the most widely used being the CHA2DS2-VASc score. Nonetheless there are several limitations to the various scores currently in clinical use and a critique of these is the focus of this review. In this review we discuss the pathophysiology of atrial fibrillation and its role in thromboembolic stroke risk. We amalgamate this with the basis of major professional society anticoagulation recommendations with regards to the strengths and limitations of current risk stratification strategies and discuss gaps in our current evidence base and next steps to address those gaps.