Stroke Rate Research Articles

The Impact of Epiaortic Ultrasound utilization in patients undergoing Coronary Artery Bypass Grafting

To assess whether use of epiaortic ultrasound for assessment of aortic calcification impacts the rate of postoperative stroke following coronary artery bypass grafting (CABG). This was a retrospective study using an institutional database of CABGs performed from 2010 to 2023. All patients undergoing isolated index CABG were included. Patients were dichotomized according to the use of epiaortic ultrasound for intraoperative aortic assessment. Postoperative stroke rates were compared, and multivariable logistic regression for postoperative stroke was performed. Cox regression was performed for the multivariable analysis of mortality. A total of 10,049 patients underwent isolated index CABG. Intraoperative epiaortic ultrasound was utilized in 1,572 (15.6%) of these patients. The STS predicted risk of stroke was 1% and did not differ between the two groups. Postoperative stroke occurred in 13 patients in the epiaortic ultrasound group (0.8%) versus 116 patients in the group in which epiaortic ultrasound was not used (1.4%, p=0.08). On multivariable logistic regression, use of epiaortic ultrasound was not associated with a reduced odds of postoperative stroke (OR 0.62, 95% CI 0.34-1.14, p=0.12). Epiaortic ultrasound use was also not significantly associated with hazards of mortality on Cox regression (HR 1.14, 95% CI: 0.94, 1.38, p=0.12). Postoperative stroke was significantly associated with an increased hazard of death (HR 2.25, 95% CI: 1.61-3.14, p<0.001). Stroke rates after CABG were 0.8% and 1.4% with and without the use of epioartic ultrasound, respectively. The current study did not find an independent association between epiaortic ultrasound use and postoperative stroke.

Predictors of ischemic stroke in Chagas disease: Insights into mechanisms beyond cardiomyopathy severity

BackgroundChagas disease is a risk factor for ischemic stroke, which causes high mortality rates and significant disability. This study aims to determine the incidence and risk factors for ischemic strokes in a large cohort of Chagas cardiomyopathy patients, with a particular focus on the mechanisms involved in the pathophysiology of stroke in this condition. MethodsThe study enrolled 517 patients with Chagas cardiomyopathy who were referred to our institution from March 2000 to December 2021. All patients underwent systematic cardiological and neurological assessments. The primary outcome was the occurrence of ischemic stroke during the follow-up period, classified based on the SSS-TOAST and CCS criteria. Natural cubic splines functions were applied to examine the potential nonlinear association between continuous variables and stroke risk. ResultsThe mean age of the cohort was 52 ± 13 years, and 299 (58 %) were men. During a mean follow-up period of 4.8 years (interquartile range-IQR 1.1 to 7.1 years), a total of 72 patients (14.8 %) had an ischemic stroke, being fatal in 10. The overall incidence rate of ischemic stroke was 3.0/100 patient-years (95 % confidence interval 2.4 to 3.8). The stroke subtypes were cardioembolic (n = 41), undetermined (n = 11), and other subtypes (n = 20). The predictors of stroke were age, left atrial volume, left ventricular ejection fraction (LVEF), LV thrombus and prior stroke with thrombus. There was a nonlinear relationship between stroke risk, LVEF, and left atrial volume. A bimodal distribution of stroke occurrences was observed according to the severity of LV dysfunction, with a threshold for LVEF of 45 %. The final model for stroke risk prediction showed good discrimination, with a C statistic of 0.775. ConclusionsIn a contemporary cohort of Chagas disease patients with a broad spectrum of disease severity, stroke incidence remains high despite anticoagulation. Stroke risk shows a nonlinear association with ventricular dysfunction and left atrial size, highlighting a distinct bimodal pattern of stroke occurrence in Chagas disease.

Comparing percutaneous coronary intervention and coronary artery bypass grafting for left main stenosis on the basis of current regional registry evidence

ObjectivesThere is an ongoing debate whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is the better choice for treatment of left main (LM) stenosis. We aimed to provide external validation for the recently reviewed guideline recommendations for invasive LM therapy by evaluating the impact of CABG or PCI on long-term survival from local reports of different regions in the world. We performed a systematic review and meta-analysis to address contemporary registry studies comparing PCI and CABG for patients with LM stenosis. MethodsThree databases were assessed. Our primary end point was long-term all-cause mortality. Secondary end points were major adverse cardiovascular events (MACE), myocardial infarction, repeat revascularization, stroke, and periprocedural mortality. Reconstruction of time-to-event data was performed. ResultsA total of 2477 studies were retrieved. Seven studies with risk-adjusted populations were selected for the analysis. Four studies favored CABG and 3 studies showed no difference for the primary end point. Compared with PCI, patients who underwent CABG had lower risk of death (hazard ratio, 1.15; 95% confidence interval, 1.05-1.26, P < .01) and MACE (hazard ratio, 1.54; 95% confidence interval, 1.40-1.69, P < .01) during follow-up. Moreover, PCI was associated with more myocardial infarction, repeat revascularization, but less strokes when compared with CABG. There was no significant difference regarding periprocedural mortality. The MACE rate was lower after CABG in both early and late phase, which outweighs the higher rate of periprocedural stroke after CABG. ConclusionsRegional registry evidence supports the current notion of superior long-term endpoints with CABG compared with PCI for the treatment of LM stenosis over time.

Comparative Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Atrial Fibrillation Patients with Chronic Liver Disease: A Systematic Review and Meta-analysis.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia. Direct oral anticoagulants (DOACs), with superior efficacy and safety, have emerged as a promising alternative to warfarin. This systematic review and meta-analysis aimed to compare the safety and efficacy of DOACs and warfarin in patients with AF and chronic liver disease (CLD). A systematic search was undertaken in PubMed, the Cochrane Library, and Google Scholar to identify studies comparing the effectiveness of DOACs and warfarin in patients diagnosed with AF and CLD. Subsequent analyses were carried out using the random-effects model. This meta-analysis included eight studies involving 20,684 participants; baseline characteristics indicated a prevalent male presence (56.7%), with an average age of 61.63 ± 9 years. Primary outcomes demonstrated that DOACs were associated with significantly reduced all-cause mortality (relative risk [RR], 0.73; 95% confidence interval [CI], 0.56-0.95; I 2 = 84%; P = .02) and ischemic stroke risk (RR, 0.62; 95% CI, 0.45-0.86; I 2 = 61%; P = .004). Secondary outcomes revealed a significantly reduced risk of major bleeding with DOACs compared to warfarin, while gastrointestinal bleeding showed a non-significant decrease. Intracranial hemorrhage risk was significantly lower with DOACs compared to warfarin. DOACs demonstrate superior safety and efficacy compared to warfarin, evidenced by reduced rates of all-cause death, ischemic stroke, severe bleeding, and cerebral hemorrhage. Further randomized controlled trials are essential to enhance the evidence base for DOACs across diverse patient populations.

Operative Times and Outcomes of Complex Endovascular Repairs of Thoracoabdominal Aneurysms

IntroductionOwing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs (eTAAA) have become increasingly common, but still carry substantial risk. These repairs require large bore access, with resultant pelvic and lower extremity ischemia. We therefore hypothesized that operative timing would be associated with outcomes, as efficient surgery would limit the ischemic time as well as anesthesia time. MethodsWe studied all eTAAA repairs (Crawford Types 1-3, 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a sub-analysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes including mortality, thoracoabdominal life altering events (TALE:composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury (AKI), major adverse cardiac events (MACE), myocardial infarction, and dialysis. ResultsThere were 2,925 eTAAA repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female, and higher rates of prior stroke, and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly employed PMEGs or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4 to 13-fold higher odds in the highest quartiles. Spinal cord ischemia had the strongest association with procedure times, with seven-fold higher odds (OR 7.2 [2.9-17.9], P<.001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR 13.1 [3.9-44.7], P<.001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (HR 2.7 [1.4-5.1], P=.002). ConclusionLonger operating times for complex eTAAA repairs were associated with markedly higher rates of morbidity and mortality, especially spinal cord ischemia. These results emphasize the importance of expeditious repairs by experienced teams.

Propensity score-based comparison of high-risk coronary artery bypass grafting vs. left ventricular assist device implantation in patients with coronary artery disease and advanced heart failure.

Revascularization in patients with severely reduced left ventricular function and coronary artery disease (CAD) is associated with a high perioperative risk. In this setting, implantation of a durable left ventricular assist device (LVAD) might be an alternative. We retrospectively compared the outcomes of adult patients with CAD and a left ventricular ejection fraction (LVEF) ≤ 25% who underwent coronary artery bypass grafting (CABG) vs. LVAD implantation. Propensity score (PS) matching was performed for statistical analysis, resulting in 168 pairs. In the PS-matched cohorts, the mean age was 62 years; one third had a history of myocardial infarction, 11% were resuscitated, half of the patients were on inotropic support, and 20% received preoperative mechanical circulatory support. LVAD patients required significantly longer ventilation (58 h [21, 256] vs. 16 h [9, 73], p < 0.001) and had a longer ICU stay (11d [7, 24] vs. 4d [2, 10], p ≤ 0.001) compared to CABG patients The incidence of postoperative renal replacement therapy (2 [1.2%] vs.15 [8.9%], p = 0.002) and temporary mechanical circulatory support was lower in the LVAD group (1 [0.6%] vs. 51 [30.4%], p ≤ 0.001). The in-hospital stroke rate was similar (LVAD 7 [5.4%] vs. CABG 8 [6.2%], p = 0.9). In-hospital survival, 1-year survival, and 3-year survival were 90.5% vs. 85.5% (p = 0.18), 77.4% vs. 68.9% (p = 0.10) and 69.6% vs. 45.9% (p < 0.001), for CABG and LVAD patients respectively. Patients with CAD and advanced HF demonstrate better mid-term survival if they undergo CABG rather than LVAD implantation.

Breaking boundaries: exploring recent advances in anticoagulation and thrombosis management: a comprehensive review

Background: Thromboembolic disorders globally contribute to morbidity and mortality, emphasizing adequate anticoagulation and thrombosis management. Therapeutic advances are essential in preventing complications like pulmonary embolism, stroke, and myocardial infarction. This review summarizes recent anticoagulation advances, current challenges, future directions, and novel anticoagulants and drug delivery systems on clinical outcomes. Methods: This paper assesses the effectiveness and safety of new anticoagulants through a systematic review of recent clinical trials, meta-analyses, and guideline publications. Key studies, including PACIFIC-AF, RIVER, ENAVLE, ENVISAGE-TAVI AF, and ARCADIA, were analyzed to provide a perspective on therapeutic advancements. Results: The review highlights key findings from vital clinical trials. Asundexian, in the PACIFIC-AF trial, demonstrated a 34% reduction in bleeding events compared to Apixaban. In the RIVER trial, Rivaroxaban reduced significant bleeding events by 20% compared to warfarin in patients with bioprosthetic mitral valves. In the ENAVLE trial, Edoxaban achieved a 3.7% decrease in thromboembolic events compared to warfarin without increasing significant bleeding rates. In the ENVISAGE-TAVI AF trial, edoxaban was non-inferior to VKAs in preventing thromboembolic events but showed a slight increase in major bleeding events by 1.5%. Lastly, the ARCADIA trial highlighted that apixaban did not significantly reduce recurrent stroke risk compared to aspirin, with both treatments having an annualized stroke rate of 4.4%. Conclusion: Advances in anticoagulant therapies and drug delivery systems aim to enhance patients’ clinical outcomes for thromboembolic disorders. While recent trials show promising data, ongoing patient-specific responses and monitoring challenges require further research. Continuous innovation and investigation are essential to refine anticoagulation practices and tailor treatments.

TCT-903 Association of TVT Site Risk Adjusted Stroke Rates and Joint Commission Stroke Certification Designation Level

TCT-903 Association of TVT Site Risk Adjusted Stroke Rates and Joint Commission Stroke Certification Designation Level

Analyzing stroke burden and risk factors in India using data from the Global Burden of Disease Study.

Stroke remains a critical global health issue, significantly impacting India with substantial contributions to mortality and disability. This study comprehensively analyses stroke incidence, mortality, and disability-adjusted life years (DALYs) across India from 1990 to 2021, using the latest Global Burden of Disease (GBD) 2021 data. We evaluate how Universal Health Coverage (UHC), health expenditure, human development index (HDI), and gross national income (GNI) influence stroke outcomes. Our findings reveal significant regional disparities, with higher stroke rates in urban areas and states like Goa and Kerala. Higher health expenditure and HDI are linked to lower stroke rates, while higher GNI per capita correlates with increased stroke incidence, likely due to lifestyle changes. Risk factors include air pollution, tobacco use, dietary risks, and high blood pressure. Air pollution notably impacts stroke mortality in Bihar and Jharkhand, while tobacco use is a major risk factor in Mizoram and Manipur. Dietary risks and hypertension are prevalent in Maharashtra and Jammu & Kashmir. The study highlights the need for targeted public health strategies addressing regional disparities and socioeconomic factors. Policymakers should focus on lifestyle modification programs, public awareness campaigns, and enhanced access to quality stroke care to reduce stroke-related morbidity and mortality effectively.

Aortic and Mitral Valve Endocarditis-Simply Left-Sided Endocarditis or Different Entities Requiring Individual Consideration?-Insights from the CAMPAIGN Database.

Background: Aortic valve infective endocarditis (AV-IE) and mitral valve infective endocarditis (MV-IE) are often grouped together as one entity: left-sided endocarditis. However, there are significant differences between the valves in terms of anatomy, physiology, pressure, and calcification tendency. This study aimed to compare AV-IE and MV-IE in terms of patient characteristics, pathogen profiles, postoperative outcomes, and predictors of mortality. Methods: We retrospectively analyzed data from 3899 patients operated on for isolated AV-IE or MV-IE in six German cardiac surgery centers between 1994 and 2018. Univariable and multivariable analyses were performed to analyze the risk factors for 30 day and 1 year mortality. A Log-rank test was used to test for differences in long-term mortality. Results: Patients with MV-IE were more likely to be female (41.1% vs. 20.3%.; p < 0.001). Vegetation was detected more frequently in the MV-IE group (66.6% vs. 57.1%; p < 0.001). Accordingly, the rates of cerebral embolic events (25.4% vs. 17.7%; p < 0.001) and stroke (28.2% vs. 19.3%; p < 0.001) were higher in the MV-IE group. Staphylococci had a higher prevalence in the MV-IE group (50.2% vs. 36.4%; p < 0.001). Patients with MV-IE had comparable 30 day mortality (16.7% vs. 14.6%; p = 0.095) but significantly higher 1 year mortality (35.3% vs. 29.0%; p < 0.001) than those with AV-IE. Kaplan-Meier survival analysis showed significantly lower long-term survival in patients with MV-IE (log-rank p < 0.001). Conclusions: Due to the relevant differences between MV-IE and AV-IE, it might be useful to provide individualized, valve-specific guideline recommendations rather than general recommendations for left-sided IE.

Multicenter retrospective cohort study demonstrates superior safety profile of indobufen over aspirin for Post-CABG antiplatelet therapy.

Coronary artery bypass grafting (CABG) is essential for treating coronary artery disease, with postoperative aspirin crucial to prevent graft restenosis. However, its gastrointestinal side effects may limit tolerability in some patients. Indobufen presents a potential alternative, but its safety and efficacy need further validation. This study aimed to compare the efficacy and safety of indobufen versus aspirin in patients' post-CABG. This retrospective observational study included 39 patients who underwent CABG at two centers from January to December 2023. Patients were retrospectively assigned to two groups based on the antiplatelet therapy they received: the indobufen group (n = 19) and the aspirin group (n = 20). The primary endpoint was a composite of non-fatal myocardial infarction, stroke, and revascularization due to acute coronary syndrome in the intention-to-treat population. Postoperative data on platelet count, hemoglobin, D-dimer, activated partial thromboplastin time (APTT), and hospital stay length were collected. Transfusion rate, bleeding, thrombotic events, and gastrointestinal adverse reactions were compared between the two groups. Over the 8-to-18-month follow-up period, 5 patients (25%) in the aspirin group reached the primary endpoint, while none in the indobufen group did, a difference that was statistically significant (p = 0.02). Although the rates of non-fatal myocardial infarction, revascularization, stroke, and thrombotic events were higher in the aspirin group, these differences did not reach statistical significance. Importantly, the total bleeding events were markedly lower in the indobufen group (15.79% vs. 55%, p = 0.011), with major bleeding events also significantly reduced in the indobufen group (0% vs. 20%, p = 0.04). Both groups showed no significant differences were observed in postoperative hospital stay, hemoglobin, and D-dimer levels between the groups. However, the indobufen group demonstrated significantly lower platelet count and APTT. The average daily cost of indobufen was 27.8 times higher than that of aspirin. Indobufen demonstrates a comparable antiplatelet effect to aspirin and offers significant advantages in reducing gastrointestinal adverse reactions and bleeding risk. It can be considered a preferable alternative for patients who cannot tolerate or have contraindications to aspirin. Further large-scale clinical trials are needed to confirm its potential as the first-choice antiplatelet therapy post-CABG.

Air pollution below US regulatory standards and cardiovascular diseases using a double negative control approach

Growing evidence suggests that long-term air pollution exposure is a risk factor for cardiovascular mortality and morbidity. However, few studies have investigated air pollution below current regulatory limits, and causal evidence is limited. We use a double negative control approach to examine the association between long-term exposure to air pollution at low concentration and cardiovascular hospitalizations among US Medicare beneficiaries aged ≥65 years between 2000 and 2016. The expected values of the negative outcome control (preceding-year hospitalizations) regressed on exposure and negative exposure control (subsequent-year exposure) are treated as a surrogate for omitted confounders. With analyses separately restricted to low-pollution areas (PM2.5 < 9 μg/m³, NO2 < 75.2 µg/m3 [40 ppb], warm-season O3 < 88.2 μg/m3 [45 ppb]), we observed positive associations of the three pollutants with hospitalization rates of stroke, heart failure, and atrial fibrillation and flutter. The associations generally persisted in demographic subgroups. Stricter national air quality standards should be considered.

Impact of Preoperative Sinus Rhythm on Concomitant Surgical Ablation's One-Year Success in Patients with Atrial Fibrillation: A Prospective Registry Cohort Study.

Background: The surgical ablation (SA) of atrial fibrillation (AF) during cardiac surgery is performed in only 8-40% of patients. We performed a subgroup analysis of the 1-year follow-up from the German CArdioSurgEry Atrial Fibrillation (CASE-AF) registry to determine how preoperative sinus rhythm (SR) prior to SA affected the outcomes. Methods: The CASE-AF registry enrolled AF patients scheduled for cardiac surgery with concomitant SA. The in-hospital and one-year follow-up data were collected prospectively and analyzed retrospectively. Results: From September 2016 to August 2020, 964 patients were enrolled in the CASE-AF registry. Among them, 333 patients were in SR immediately before surgery (study cohort). A complete follow-up was achieved for 95.6%. Both the severity of the AF (modified European Heart Rhythm Association symptom classification, p < 0.001) and the frequency of AF symptoms (p = 0.006) were significantly reduced at one year compared to the preoperative baseline. Almost 90 percent of the patients underwent left atrial appendage occlusion (LAAO) during the procedure. The one-year mortality (4.1%) and stroke rates (3.2%) were low. SR was evident in 70.3% of the patients at the one-year follow-up. Conclusions: Patients with AF who have SR at the time of surgery should not be excluded from SA, as it appears to be a safe and effective procedure.

Redo surgical aortic valve replacement for bioprosthetic structural valve deterioration.

To compare isolated primary bioprosthetic surgical aortic valve replacement (SAVR) with isolated redo surgical aortic valve replacement (rSAVR) due to structural valve deterioration (SVD). Clinical data of consecutive patients who underwent primary isolated SAVR and isolated rSAVR due to SVD between January 1, 2011, and December 31, 2022, at Leipzig Heart Center were retrospectively compared with regard to the primary outcome of all-cause mortality or stroke during hospitalization. Secondary outcomes of interest included myocardial infarction, re-exploration for bleeding, and permanent pacemaker implantation. A total of 2620 patients, 39.5% females, with a median EuroSCORE II of 1.7 (interquartile Range [IQR] 1.1; 2.7] were identified, of which rSAVR was performed in 174 patients (6.6%). Patients undergoing primary SAVR were older (69 versus 67 years of age, p = 0.001) and were less likely to have a history of prior stroke (0.9% versus 4.0%, p = 0.003). Although both all-cause death and death or stroke occurred less often following primary SAVR (0.5% versus 5.8%, and 2.2% versus 6.9%, respectively; p < 0.001), prior surgery was not associated with adverse clinical outcome in multivariable analysis. In a matched comparison of 322 patients, rates of death or stroke did not differ between groups (4.8% for both rSAVR and SAVR, p = 1.0). Although redo surgery for SVD is associated with increased rates of early mortality and stroke by univariate analysis, much of this increased risk can be accounted for by comorbidities. Patients undergoing rSAVR on an elective basis can expect an outcome similar to that of primary SAVR.

Morphological characteristics and outcomes of aortic repair of acute type A aortic dissection occurring in patients with aortic arch branching variants.

To investigate the morphological characteristics and operative outcomes of acute type A aortic dissection (ATAAD) in patients with aortic arch variants. Of 616 patients with ATAAD, 97 (15.7%) had aortic arch variants, including bovine aortic arch (BAA, n = 66), isolated left vertebral artery (ILVA, n = 25), and aberrant subclavian artery (ASA, n = 6). The characteristics and outcomes were compared between the normal branching group (control, n = 519) and the total/individual arch variant groups. Compared to the control group, arch entry was more prevalent in the BAA (18.5% vs. 31.8%) and ILVA groups (44%) (both, P < 0.05), and right common carotid arterial occlusion was less common in the arch variant group (6.7% vs. 0%, P = 0.017). The in-hospital mortality (9.2% vs. 9.3%), new-onset stroke (7.3% vs. 7.2%), and 5-year survival (81.7% vs. 78.8%) did not differ markedly between the control and arch variant groups. Arch repair was performed in 28.9% (28/97) of the arch variant group using 3-4 vessel antegrade cerebral perfusion, with 3.8% in-hospital mortality and a 15.4% stroke rate, which were comparable to those of the control group. Aortic arch variants may influence tear location and involvement of the supra-arch vessels but may not affect postoperative outcomes.

Association between serum iron levels and atherosclerotic cardiovascular diseases among American older adults: a cross-sectional study based on the National Health and Nutrition Examination Survey, 2009-2018.

There is controversy regarding the relationship between serum iron levels and atherosclerotic cardiovascular disease (ASCVD). To investigate the relationship between serum iron levels and ASCVD among older adults using data from the 2009-2018 National Health and Nutrition Examination Survey (NHANES). We performed a cross-sectional analysis involving 8,682 participants aged 60 years and older, with complete data on serum iron levels and confirmed ASCVD status, sourced from the 2009-2018 National Health and Nutrition Examination Survey (NHANES). Multivariable logistic regression models were used to examine the association between serum iron levels and ASCVD. To assess the consistency of this association across different demographic groups, subgroup analyses, and interaction tests were performed. The group with the highest serum iron levels (fourth quartile, 100-369 μg/dL) exhibited several distinct characteristics: they were the youngest on average (69.57 ± 6.91 years), had the highest proportion of males (61.42%), and the highest hemoglobin levels (14.43 ± 1.33 g/dL). This group also showed the lowest iron supplement usage (19.71 ± 12.85 mg/30 days), white blood cell counts (6.73 ± 2.41 1,000 cells/μL), and serum creatinine levels (0.98 ± 0.45 mg/dL). Moreover, they had higher levels of education and income, a higher likelihood of being married, and a lower body mass index (BMI). Additionally, they had significantly lower rates of diabetes, hypertension, stroke, and heart attacks (all p < 0.05). After adjusting for potential confounders, a linear relationship between serum iron levels and ASCVD was initially observed (OR = 0.97; 95% CI, 0.95-0.99, p < 0.05). However, further analysis using a two-part logistic regression model with an inflection point at 131 μg/dL revealed more nuanced results. For serum iron levels below 131 μg/dL, each 10 μg/dL increase was associated with a 4% decrease in the odds of ASCVD (OR = 0.96; 95% CI, 0.93-0.98, p < 0.001). Conversely, for serum iron levels above 131 μg/dL, each 10 μg/dL increase corresponded to a 1% increase in the odds of ASCVD, though this finding was not statistically significant (OR = 1.01; 95% CI, 0.98-1.08, p > 0.05). In the US elderly population, serum iron levels are negatively associated with ASCVD, particularly when serum iron levels are below 131 μg/dL.

Prediction of Severe Baseline Asymptomatic Carotid Stenosis and Subsequent Risk of Stroke and Cardiovascular Disease.

Risk models to identify patients at high risk of asymptomatic carotid artery stenosis (ACAS) can help in selecting patients for screening, but long-term outcomes in these patients are unknown. We assessed the diagnostic and prognostic value of the previously published Prevalence of ACAS (PACAS) risk model to detect ACAS at baseline and to predict subsequent risk of stroke and cardiovascular disease (CVD) during follow-up. We validated the discrimination and calibration of the PACAS risk model to detect severe (≥70% narrowing) ACAS with patients from the Reduction of Atherothrombosis for Continued Health registry. We subsequently calculated the incidence rates of stroke and CVD (fatal and nonfatal stroke or myocardial infarction or vascular death) during follow-up in 4 risk groups (low, medium, high, and very high, corresponding to sum scores of ≤9, 10-13, 14-17, and ≥18, respectively). Among 26 384 patients, aged between 45 and 80 years, without prior carotid procedures, 1662 (6.3%) had severe baseline ACAS. During ≈70 000 patient-years of follow-up, 1124 strokes and 2484 CVD events occurred. Discrimination of the PACAS model was 0.67 (95% CI, 0.65-0.68), and calibration showed adequate concordance between predicted and observed risks of severe baseline ACAS after recalibration. Significantly higher incidence rates of stroke (Ptrend<0.011) and CVD (Ptrend<0.0001) during follow-up were found with increasing PACAS risk groups. Among patients with high PACAS sum score of ≥14 (corresponding to 27.7% of all patients), severe baseline ACAS prevalence was 11.4%. In addition, 56.6% of incident strokes and 64.9% of incident CVD events occurred in this group. The PACAS risk model can reliably identify patients at high risk of severe baseline ACAS. Incidence rates of stroke and CVD during follow-up were significantly higher in patients with high PACAS sum scores. Selective screening of patients with high PACAS sum scores may help to prevent future stroke or CVD.

Rates of strokes in Californians with sickle cell disease in the post-STOP era

AbstractNeurovascular complications, including strokes and transient ischemic attacks (TIAs), are common and cause significant morbidity in individuals with sickle cell disease (SCD). The Stroke Prevention Trial in Sickle Cell Anemia (STOP) (1998) established chronic transfusions as the standard of care for children with SCD at high risk for stroke. Using statewide emergency department and hospitalization data from the California Department of Health Care Access and Innovation (1991-2019), we determined the cumulative incidence and rates of primary and recurrent strokes and TIAs in people with SCD before and after the STOP trial. For the 7636 patients included in our SCD cohort, the cumulative incidence of the first ischemic stroke was 2.1% (95% confidence interval [CI], 1.8-2.4) by the age of 20 years and 13.5% (95% CI, 12.3-14.7) by the age of 60 years. The cumulative incidence of the first intracranial hemorrhage (ICH) was 0.5% (95% CI, 0.4-0.7) by the age of 20 years and 6.8% (95% CI, 5.9-7.7) by the age of 60 years. Ischemic stroke rates increased in children (age <18 years; 234.9 vs 165.1 per 100 000 PY; P = .012) and adults (age 31-50 years; 431.1 vs 303.2 per 100 000 PY; P = .031) in 2010 to 2019 when compared with the preceding decade. There was an increase in the rates of ICH in those aged 18 to 30 years and TIA in children <18 years from 2010 to 2019 when compared with the previous decade. Risk factors for stroke and TIA included increasing age, hypertension, and hyperlipidemia. These findings underscore the need for prevention of strokes in adults with SCD and suggest an emphasis on the management of modifiable cerebrovascular risk factors that have been demonstrated to be effective in the general population.

Prevalence of vitamin C deficiency and its association with stroke risk among U.S. adult population: A cross-sectional analysis spanning 15 years with over 13,000 participants

Background: Stroke presents a significant global health challenge. Despite its potential for cardiovascular protection, the role of vitamin C (VTMC) in stroke risk remains contentious. Aim: This study aimed to assess VTMC deficiency in stroke patients and its association with stroke risk. Methods: We analyzed data from 13,339 adults aged 20 and above in the National Health and Nutrition Examination Survey (NHANES) between 2003 and 2018, excluding those with missing serum VTMC and stroke status. We assessed the VTMC deficiency (&lt;11.4 µmol/L) and stroke incidence association using multivariate weighted logistic regression, adjusting for demographics, BMI, medical history, smoking, and dietary VTMC intake. Results: Stroke rates in the NHANES cycles 2003–2006 and 2017–2018 were 2.8% (95% CI [2.3–3.4]) and 3.3% (95% CI [2.7–4.2]), respectively. VTMC deficiency was more common in individuals with a history of stroke, with rates of 3.6% (95% CI [2.2–5.8]) and 5.3% (95% CI [3–9.1]) compared to 2.7% (95% CI [2.3–3.3]) and 3.2% (95% CI [2.5–4.1]) in the nonstroke population. Nevertheless, VTMC deficiency was distinctly prevalent across diverse demographic and health-related subgroups. Multivariate analyses invalidated any statistically significant association between VTMC deficiency and stroke risk across all employed analytical models within both time intervals. Conclusions: Our study does not support a link between VTMC deficiency and increased stroke risk in U.S. adults. Substantial uncertainties persist regarding the use of VTMC for stroke-related oxidative stress, dosage, and delivery methods, requiring further clinical trials. Healthcare providers should carefully consider its prevalence in specific subgroups.

Effect of impaired kidney function on outcomes and treatment effects of oral anticoagulant regimes in patients with atrial fibrillation in a real-world registry.

The impact of impaired kidney function on outcomes and treatment benefits of vitamin-K antagonists (VKA) versus direct oral anticoagulants (DOAC) in patients with atrial fibrillation (AF) has insufficiently been investigated in randomized controlled studies (RCTs). Most studies and registries are either biased due to incomplete enrolment of consecutive patients in large pharma industry sponsored registries, or due to short recruitment periods or incomplete assessment of important variables in national registries. This study uses data from the Heidelberg Registry of Atrial Fibrillation (HERA-FIB), a retrospective single-center registry of 10,222 consecutive patients with AF presenting to the emergency department of University Hospital of Heidelberg from June 2009 until March 2020. Rates of all-cause mortality, stroke, major bleeding and myocardial infarction (MI) were related to the presence and severity of impaired presenting kidney function, as well as to assigned treatment with VKA vs. DOAC. The risks for all-cause mortality (HR: 3.26, p<0.001), stroke (HR: 1.58, p<0.001), major bleeding (HR: 2.28, p<0.001) and MI (HR: 2.48, p<0.001) were significantly higher in patients with an eGFR<60 ml/min at admission and increased with decreasing eGFR. After adjustment for variables of CHA2DS2VASc-score, presence of eGFR <60 ml/min remained as an independent predictor for all-cause mortality, major bleeding and MI. The hazard ratio (HR) for all-cause mortality, major bleedings and MI was significantly lower in patients receiving DOAC compared to VKA. Findings from our large real-life registry confirm the data from RCTs and extend our knowledge on the effectiveness and safety of DOACs to subjects that were underrepresented in RCTs.