Rate Of Transient Ischemic Attack Research Articles

Asymptomatic Patients With a Remote History of Transient Ischemic Attack or Stroke May Benefit From Reduced Hazard of In-hospital Death After Transcarotid Artery Revascularization

Asymptomatic patients with remote history of transient ischemic attack (TIA) or stroke are not well-studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients with and without a history of TIA or stroke. Data from patients in the Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke within 180 days before procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic A) and TIA and/or stroke occurring more than 180 days before the procedure (asymptomatic B). The Student t test and χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. There were 7158 patients who underwent TCAR (symptomatic: 2574; asymptomatic A: 3689; asymptomatic B: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195; asymptomatic A: 10,333; asymptomatic B: 1495). TCAR patients were generally older, White, smokers, and had more comorbidities than TFCAS. Asymptomatic B patients had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic A patients, and these rates were similar to those of symptomatic patients (Table). Comparing TCAR and TFCAS among asymptomatic B patients, there were statistically significant reductions in the odds of stroke/death (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.27-0.84; P = .011) and stroke/death/myocardial infarction (OR, 0.51; 95% CI, 0.30-0.87; P = .013) after TCAR. A greater reduction in the odds of death was observed among asymptomatic B patients (OR, 0.30; 95% CI, 0.084-1.110; P = .069) compared with asymptomatic A patients (OR, 0.41; 95% CI, 0.20-0.85; P = .017), which was likely driven by the increased rate of death for TFCAS asymptomatic B patients (0.9%) compared with asymptomatic A (0.6%) Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Asymptomatic patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.TablePercent incidence and adjusted odds ratio (aORs) for in-hospital outcomesIn-hospital eventsSymptomaticAsymptomatic A: No history of TIA/strokeAsymptomatic B: Remote history of TIA/StrokeTCAR (%)TFCAS (%)Odd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTIA0.710.66 (0.39-1.13).130.40.60.60 (0.31-1.16).131.11.30.76 (0.34-1.70).50Stroke2.13.10.63 (0.46-0.87).0040.81.40.50 (0.32-0.78).0021.92.50.70 (0.38-1.28).25Death0.62.70.18 (0.10-0.30)<.0010.20.60.41 (0.20-0.85).0170.30.90.30 (.084-1.10).069TIA/stroke2.840.63 (0.48-0.82)<.0011.12.00.52 (0.36-0.76)<.0012.83.70.67 (0.41-1.11).12Stroke/death2.45.10.41 (0.31-0.54)<.0011.01.90.48 (0.33-0.70)<.0011.93.30.46 (0.27-0.84).011Stroke/death/MI3.05.70.45 (0.35-0.58)<.0011.42.30.54 (0.39-0.75)<.0012.33.80.51 (0.30-0.87).013MI0.60.80.73 (0.41-1.30).290.40.60.78 (0.43-1.43).430.40.60.77 (0.22-2.74).68Postoperative complications6.610.20.59 (0.49-0.70)<.0015.86.10.93 (0.77-1.13).476.76.90.95 (0.67-1.34).77CI, Confidence interval; MI, myocardial infarction; TCAR, transcarotid artery revascularization; TFAR, transfemoral artery revascularization; TIA, transient ischemic attack.Postoperative complications include any of the listed complications: reperfusion symptoms, myocardial infarction, dysrhythmia (new), congestive heart failure, access site complication, hematoma/bleeding, stenosis/occlusion, infection, pseudoaneurysm, and arteriovenous fistula.Multivariate logistic regression analysis adjusted for baseline age, ethnicity, congestive heart failure diabetes, hypertension, carotid artery disease, prior carotid endarterectomy/carotid artery stenting, smoking, race, and sex. Open table in a new tab

Clinical Events with Edoxaban in South Korean and Taiwanese Atrial Fibrillation Patients in Routine Clinical Practice.

Edoxaban is approved for stroke prevention in nonvalvular atrial fibrillation (AF) patients in numerous countries. Outcome data are sparse on edoxaban treatment in AF patients from routine clinical practice, especially in Asian patients. Global ETNA (Edoxaban in rouTine cliNical prActice) is a noninterventional study that integrates data from patients from multiple regional registries into one database. Here, we report the 1-year clinical events from AF patients receiving edoxaban in South Korea and Taiwan. Clinical events assessed included bleeding, strokes, systemic embolic events, transient ischemic attacks (TIAs), and all-cause and cardiovascular death. Overall, 2677 patients (mean (range) age 72 (66–78) years, male 59.7%, mean CHA2DS2-VASc score ± standard deviation 3.1 ± 1.4) were treated with 60 or 30 mg edoxaban and had 1-year follow-up data. The annualized event rates for major bleeding and clinically relevant non-major (CRNM) bleeding were 0.78% and 0.47%, respectively. Annualized event rates for ischemic stroke and hemorrhagic stroke were 0.90% and 0.19%, respectively. Event rates for major and CRNM bleeding and rates of ischemic stroke and TIA were higher in Taiwanese patients than in Korean patients. Event rates were low and similar to those found in other studies of edoxaban in Korean and Taiwanese AF patients, thus supporting the safety and effectiveness of edoxaban in this population.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy

ObjectiveRestenosis after carotid endarterectomy (CEA) poses unique therapeutic challenges, with no specific guidelines available on the operative approach. Traditionally, transfemoral carotid artery stenting (TfCAS) has been regarded as the preferred approach to treating restenosis after CEA. Recently, transcarotid artery revascularization with a flow-reversal neuroprotection system (TCAR) has gained popularity as an effective alternative treatment modality for de novo carotid artery stenosis. The aim of the present study was to compare the contemporary perioperative outcomes of TfCAS and TCAR in patients with prior ipsilateral CEA. MethodsThe Vascular Quality Initiative database was reviewed for patients who had undergone TfCAS and TCAR for restenosis after prior ipsilateral CEA between January 2016 and August 2020. The primary outcome was the 30-day composite outcome of stroke and death. The secondary outcomes included 30-day stroke, transient ischemic attack (TIA), myocardial infarction (MI), death, and composite 30-day outcomes of stroke, death, and TIA, stroke and TIA, and stroke, death, and MI. Multivariable logistic regression models were used to evaluate the outcomes of interest after adjustment for potential confounders and baseline differences between cohorts. ResultsOf 3508 patients, 1834 and 1674 had undergone TfCAS and TCAR, respectively. The TCAR cohort was older (mean age, 71.6 years vs 70.2 years; P < .001) and less likely to be symptomatic (27% vs 46%; P < .001), with a greater proportion taking aspirin (92% vs 88%; P = .001), a P2Y12 inhibitor (89% vs 80%; P < .001), and a statin (91% vs 87%; P = .002) compared with the TfCAS cohort. Perioperatively, the TCAR cohort had had lower 30-day composite outcomes of stroke/death (1.6% vs 2.7%; P = .025), stroke/death/TIA (1.8% vs 3.3%; P = .004), and stroke/death/MI (2.1% vs 3.2%; P = .048), primarily driven by lower rates of stroke (1.3% vs 2.3%; P = .031) and TIA (0.2% vs 0.7%; P = .031). Among asymptomatic patients, the incidence of stroke (0.6% vs 1.4%; P = .042) and the composite of stroke/TIA (0.8% vs 1.8%; P = .036) was significantly lower after TCAR than TfCAS, and TCAR was associated with a lower incidence of TIA (0% vs 1%; P = .038) among symptomatic patients. On adjusted analysis, the TCAR cohort had lower odds of TIA (adjusted odds ratio, 0.17; 95% confidence interval, 0.04-0.74; P = .019). ConclusionsAmong patients undergoing carotid revascularization for restenosis after prior ipsilateral CEA, TCAR was associated with decreased odds of 30-day TIA compared with TfCAS. However, the two treatment approaches were similarly safe in terms of the remaining perioperative outcomes, including stroke and death and stroke, death, and MI. Our results support the safety and efficacy of TCAR in this subset of patients deemed at high risk of reintervention.

1-Year Results From a Prospective Experience on CAS Using the CGuard Stent System: The IRONGUARD 2 Study.

The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry. DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year. From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion. At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30days postprocedure, 1minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90days vs 30days) was not found to be related to major adverse cardiovascular event or restenosis occurrence. This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up.

Reflux esophagitis is associated with higher risks of acute stroke and transient ischemic attacks in patients hospitalized with atrial fibrillation: A nationwide inpatient sample analysis.

Reflux esophagitis (RE) is a subset of gastroesophageal reflux disease (GERD) with endoscopic evidence of esophageal inflammation, which has been linked to an increased incidence of atrial fibrillation (AF). However, data on the effect of RE on patient outcomes is limited. We sought to examine the potential association of RE with outcomes of patients with AF in a nationwide study.The National Inpatient Sample (NIS) database was queried to identify hospitalized adult patients with AF and RE between 2010 and 2014. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges. AF related complications such as acute stroke, transient ischemic attack (TIA) and acute heart failure were assessed as secondary outcomes. Propensity score matching and multivariate regression analysis were used.Six lakh sixty seven thousands five hundred twenty patients were admitted for primary diagnosis of AF out of which 5396 had a secondary diagnosis of RE. In the AF with RE cohort, the average age was 73.6 years, 41.5% were male, and 79.9% were Caucasian. There was a greater prevalence of concomitant dyslipidemia, chronic liver disease and chronic pulmonary disease (P < .01) when compared to the AF without RE cohort. Patients with AF and RE also had higher incidence of acute strokes and TIAs (P < .05), longer LOS (P < .001), and higher hospital charges (P < .05) with no difference in acute heart failure (P = .08), hospital mortality (P = .12), or CHA2DS2-VASc score (P = .67).In hospitalized patients with AF, RE was associated with a higher rate of acute stroke and TIAs, longer LOS, and greater hospital charges.

Trends in Cerebral Embolic Protection Device Use and Association With Stroke Following Transcatheter Aortic Valve Implantation

Stroke remains a serious complication of transcatheter aortic valve implantation (TAVI). Prior studies examining the association between cerebral embolic protection device (CEPD) use and stroke following TAVI have produced conflicting results. We used the Nationwide Readmissions Databases to identify all percutaneous (non-transapical) TAVIs performed in the US from July, 2017 to December, 2018. Overlap propensity score weighted logistic regression models were used to determine the association between CEPD use and outcomes. The primary outcome was in-hospital stroke or transient ischemic attack (TIA). Among 50,000 percutaneous TAVIs (weighted national estimate: 88,886 [SE: 2,819]), CEPD was used in 2,433 (weighted national estimate: 3,497 [SE: 857]). Nationally, the utilization rate of CEPD was 3.9% (SE: 0.9%) of all TAVIs during the overall study period, which increased from 0.8% (SE: 0.4%) in 2017Q3 to 7.6% (SE: 1.6%) in 2018Q4 (p<0.001). The proportion of hospitals using CEPD increased from 2.3% in 2017Q3 to 14.7% in 2018Q4 (p<0.001). There were no significant differences in rates of in-hospital stroke/TIA in TAVIs with versus without CEPD (2.6% vs 2.2%; unadjusted OR [95% CI] 1.18 [0.98-1.52]; overlap propensity score weighted OR [95% CI] 1.19 [0.81-1.75]). CEPD use was not associated with statistically significant lower rates of in-hospital stroke, ischemic stroke, hemorrhagic stroke, TIA, all-cause mortality, or discharge to skilled nursing facility. In conclusion, the rates of CEPD utilization and proportion of TAVI hospitals using CEPD increased during the study period. The use of CEPD during TAVI was not associated with statistically significant lower rates of in-hospital stroke, TIA, or mortality.

Incidence of acute ischemic cerebrovascular events in a cohort of HIV-infected patients.

The prevalence of vascular diseases in HIV (human immunodeficiency virus)-infected individuals has been comprehensively investigated. However, their incidence of ischemic cerebrovascular events has not been thoroughly examined. Our aim was to examine the rate of ischemic stroke or TIA (transient ischemic attack) in a defined HIV population and to find the risk factors that are characteristic in this population. A case-controlled retrospective cohort study of HIV patients followed up at Kaplan Medical Center between 2009 and 2017 was performed. The study included 300 patients who had been compared to a matched age and gender group. The data were collected by reviewing patients' files and imaging studies. The first goal was to compare the incidence of ischemic cerebrovascular events in both groups. Secondary endpoints were to characterize the types of cerebrovascular events and risk factors in the study group versus the general population. There were more ischemic stroke cases in the study group vs. the control group. After adjusting for vascular risk factors in a multivariate analysis, the odds ratio for a cerebrovascular accident in the HIV patient group was 2.29 (p = 0.057). Notably, in the comparative group, the vascular risk factors' rate (hyperlipidemia, IHD and smoking) was higher than in the HIV group. In this study, ischemic cerebrovascular events were more common in HIV-infected patients than in the control group, in spite of the fact that they had fewer vascular risk factors.

The Association Between Heart Rate Variability and 90-Day Prognosis in Patients With Transient Ischemic Attack and Minor Stroke.

Background: Low heart rate variability (HRV) is known to be associated with increased all-cause, cardiovascular, and cerebrovascular mortality but its association with clinical outcomes in patients with transient ischemic attack (TIA) or minor stroke is unclear.Methods: We selected TIA and minor stroke patients from a prospective registration study. From each continuous electrocardiograph (ECG) record, each QRS complex was detected and normal-to-normal (N-N) intervals were determined. The standard deviation of all N-N intervals (SDNN) and the square root of the mean squared differences of successive N-N intervals (RMSSD) were calculated. Logistic regression analysis and Cox regression analysis were performed to assess the outcomes of patients at 90 days, and the odds and risk ratios (OR/HR) of each index quartile were compared.Results: Compared with SDNN patients in the lowest quartile, neurological disability was significantly reduced in other quartile groups at 90 days, with significant differences [OR of group Q2 was 0.659; 95% confidence interval (CI), 0.482–0.900; p = 0.0088; OR of group Q3 was 0.662; 95% CI, 0.478–0.916; p = 0.0127; OR of group Q4 was 0.441; 95% CI, 0.305–0.639; p <0.0001]. Compared with the lowest quartile, the recurrence rate of TIA or minor stroke in patients of the two higher quartiles (Q3 and Q4) of SDNN was significantly reduced at 90 days (HR of Q3 group was 0.732; 95% CI, 0.539–0.995; p = 0.0461; HR of Q4 group was 0.528; 95% CI, 0.374–0.745; p = 0.0003).Conclusions: Based on our findings, autonomic dysfunction is an adverse indicator for neurological function prognosis and stroke recurrence 90 days after TIA or minor stroke.

Transient Ischemic Attack (TIA) Incidence with Geographic Information Systems (GIS) Mapping for Stroke Prevention Interventions

Objectives:GIS mapping as a public health tool has been increasingly applied to chronic disease control. While evaluating TIA incidence from an existing regional stroke registry in Ludhiana city, India, we aim to apply the innovative concept of regional TIA GIS mapping for planning targeted stroke prevention interventions.Methods:TIA patient data was obtained from hospitals, scan centers and general practitioners from March 2010 to March 2013 using WHO-Stroke STEPS based surveillance as part of establishing a population-based stroke registry in Ludhiana city. From this registry, patients with TIA (diagnosed by MRI image-based stroke rule-out, or clinically) were chosen and data analyzed.Results:A total of 138 TIA patients were included in the final analysis. The annual TIA incidence rate for Ludhiana city was 7.13/100,000 (95% confidence interval: 5.52 to 8.74) for 2012-2013. Mean age was 58.5 ± 13.9 years (range: 22-88 years) and 87 (63%) were men. Majority of the TIA cases had anterior circulation TIAs. Hypertension (87.4%) was the most common risk factor. Using Geographic Information System (GIS) mapping, high TIA incidence was seen in central, western, and southern parts and clustering of TIA cumulative incidence was seen in the central part of Ludhiana city.Conclusion:Incidence rate of TIA was lower than that expected from a low- and middle-income country (LMIC). TIA GIS mapping, looking at regional localization, can be a novel option for developing targeted, cost-effective stroke prevention programs.

Abstract P242: Impact of Covid-19 on Acute Ischemic Stroke Care at Henry Ford Hospital’s Detroit and West Bloomfield Campuses

Background: Coronavirus 2019 (COVID19) has impacted acute stroke (AS) care with several reports globally showing drops in AS volumes during the pandemic. We studied the impact of COVID19 on AS and transient ischemic attack (TIA) care in a health system serving Southeast Michigan as we rolled out a policy aimed at limiting admissions and transfers. Methods: In this retrospective study conducted at 2 hospitals, we included consecutive patients presenting to the emergency department (ED) for whom a Stroke Alert (SA) was activated during the period 3/20 to 5/20/20 (COVID) and a similar period in 2019 (pre-COVID). We compared demographics, time metrics, and discharge outcomes. Results: 264 patients were seen pre-COVID compared to 121 during COVID (p&lt;0.001). Patients seen during COVID had an equal proportion of males (55% vs 51%, p=0.444), were majority African American (57 vs 58%, p=0.74), but had a higher presenting NIHSS (median: 5 vs 2, p=0.01) and longer times since last-known-well to ED arrival (median: 9.4 vs 4.8 hours, p=0.03) compared to pre-COVID. Fewer patients were transferred from other centers (42 vs 27% p=0.008). SA activation on arrival (median: 9.6 vs 15 min, p=0.004) and imaging initiation from arrival (median: 26.4 vs 34.8 min, p=0.042) were faster as well as a trend toward statistical significance for time to tPA administration (median: 37.8 vs 51 min, p=0.051) compared to pre-COVID. There were higher rates of AS and TIA (69% vs 55%) and lower rates of stroke mimics (17 vs 37%, p&lt;0.001). Patients discharged from the stroke unit had significantly higher discharge NIHSS (median: 3 vs 2, p=0.002) and were more likely to have an unfavorable discharge mRS (3-6) (56 vs 33%, p=0.004). There were no significant differences in medical, social histories, time to first pass for patient undergoing thrombectomy and stroke etiologies between the groups. In 2020, 9 patients (8%) were COVID19 positive, 2 had unfavorable mRS 3-5 while 3 died. Conclusion: There was greater than 50% reduction in stroke admissions during the COVID19 pandemic which is consistent with other reports. Although patients were managed more quickly, they tended to have more severe strokes, fewer stroke mimic diagnoses, and worse outcomes compared to patients treated in the pre-COVID period.

Age-Dependent Differences in the Rate and Symptoms of TIA Mimics in Patients Presenting With a Suspected TIA to a Neurological Emergency Room.

Background: Transient ischemic attack (TIA) needs further diagnostic evaluation to prevent future ischemic stroke. However, prophylaxis can be harmful in elderly if the diagnosis is wrong. We aimed at characterizing differences in TIA mimics in younger and older patients to enhance diagnostic accuracy in elderly patients.Methods: In a dedicated neurological emergency room (nER) of a tertiary care University hospital, patients with transient neurological symptoms suspicious of TIA (<24 h) were retrospectively analyzed regarding their final diagnoses and their symptoms. These parameters were compared between patients aged 18–70 and >70 years using descriptive, univariable, and multivariable statistics.Results: From November 2018 until August 2019, 386 consecutive patients were included. 271 (70%) had cardiovascular risk factors and all patients received cerebral imaging, mostly CT [376 (97%)]. There was no difference in the rate of diagnosed TIA between the age groups [85 (46%) vs. 58 (39%); p = 0.213].TIA mimics in the elderly were more often internal medicine diseases [35 (19%) vs. 7 (5%); p < 0.001] and epileptic seizures [48 (26%) vs. 24 (16%); p = 0.032] but less often migraine [2 (1%) vs. 20 (13%); p < 0.001]. The most frequent symptoms in all patients were aphasia and dysarthria [107 (28%) and 92 (24%)]. Sensory impairments were less frequent in elderly patients [23 (11%) vs. 54 (30%); p < 0.001]. Impaired consciousness and orientation were independent predictors for TIA mimics (p < 0.001) whereas facial palsy (p < 0.001) motor weakness (p < 0.001), dysarthria (p = 0.022) and sensory impairment (p < 0.001) were independent predictors of TIA.Conclusion: TIA mimics in elderly patients are more likely to be internal medicine diseases and epilepsy compared to younger patients. Excluding internal medicine diseases seems to be important in elderly patients. Facial palsy, motor weakness, dysarthria and sensory impairment are associated with TIA.

Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke

Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population. To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA. Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1). Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort). The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017. Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend). In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept.

Background:Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes.Methods:We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge.Results:A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar.Conclusions:The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.

Poststent ballooning during transcarotid artery revascularization

BackgroundPoststent ballooning/angioplasty (post-SB) have been shown to increase the risk of stroke risk after transfemoral carotid artery stenting. With the advancement of transcarotid artery revascularization (TCAR) with dynamic cerebral blood flow reversal, we aimed to study the impact of post-SB during TCAR. MethodsPatients undergoing TCAR in the Vascular Quality Initiative between September 2016 and May 2019 were included and were divided into three groups: those who received prestent deployment angioplasty only (pre-SB, reference group), those who received poststent deployment ballooning only (post-SB), and those who received both prestent and poststent deployment ballooning (prepost-SB). Patients who did not receive any angioplasty during their procedure (n = 367 [6.7%]) were excluded because these represent a different group of patients with less complex lesions than those requiring angioplasty. Primary outcome was in-hospital stroke or death. Analysis was performed using univariable and multivariable logistic regression models. ResultsOf 5161 patients undergoing TCAR, 34.7% had pre-SB only, 25% had post-SB only, and 40.3% had both (prepost-SB). No differences in the rates of in-hospital and 30-day stroke, death, and stroke/death were observed among the three groups; in-hospital stroke/death in the pre-SB group was 1.4% (n = 25), post-SB 1.2% (n = 16), and prepost-SB 1.4% (n = 29; P = .92). However, patients undergoing post-SB and prepost-SB had higher rates of in-hospital transient ischemic attacks (TIA) (post-SB, 0.9%; prepost-SB, 1% vs pre-SB, 0.2%, P < .01) and postprocedural hypotension (16.6% and 16.8% vs 13.1%, respectively; P < .001). Post-SB also had longer operative times, as well as flow reversal and fluoroscopy times. On multivariable analysis, no association was seen between post-SB and the primary outcome of in-hospital stroke/death (post-SB odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44–1.73; prepost-SB OR, 0.98; 95% CI, 0.57-1.70). Similarly, no significant differences were noted in terms of postprocedural hemodynamic instability and 30-day outcomes. However, post-SB and prepost-SB were associated with four times the odds of in-hospital TIA compared with pre-SB alone (post-SB OR, 4.24 [95% CI, 1.51-11.8]; prepost-SB OR, 4.76 [95% CI, 1.53-14.79]; P = .01). Symptomatic patients had higher rates of in-hospital stroke/death compared with their asymptomatic counterparts; however, there was no significant interaction between symptomatic status and ballooning in predicting the primary outcome. ConclusionsPost-SB was used in 65.3% of TCAR patients. This maneuver seems to be safe without an increase in the odds of postoperative in-hospital stroke/death. However, the increased rates of TIA associated with post-SB requires further investigation.

Abstract 398: Magnitude and Impact of Underutilization of Flu Vaccine in High-Risk US Cohorts on Cardiovascular Events

Background: Influenza vaccination has been shown to reduce myocardial infarction(MI) and other cardiac events. Several groups are considered at high risk for influenza and its complications. In this study, we explored the utilization and impact of flu vaccination in these high risk groups on various cardiovascular outcomes. Methods: Our retrospective cohort study compared utilization and outcomes in high risk groups among those who did receive vaccination during hospitalization versus those who did not. We analyzed utilization and impact of flu vaccine in several high-risk group identified by Center for Disease Control (CDC) i.e., adults 50 years and older, people with chronic medical conditions, AIDS patients, people at nursing facilities, American Indians and Alaskan natives, and obese people in the 2014 National Inpatient Sample Database. Results: The NIS database revealed 168,325 flu vaccinations among the 7,056,314 total high risk patients during hospitalization. Of note, the adults 50 years and older high risk cohort was less likely to be vaccinated during hospitalization at 1.8% compared to the general population at 15.3%. High risk groups benefited with flu vaccination and had reduced risk of MI, mortality, transient ischemic attacks (TIA) and cardiac arrest (Table). Conclusion: Flu vaccination was paradoxically underutilized in the high-risk patients and when used was associated with reduced rates of MI, TIA and cardiac arrest in all high risk cohorts compared to those who did not receive vaccination. These results underscore the need for health care policy initiatives to optimize flu vaccination among all patients and especially among high risk groups identified by the CDC.

Transient Ischemic Attack: The Trend and Readmissions in the United States

Introduction: Transient ischemic attack (TIA) is a temporary event of neurological dysfunction. Patients with TIA may be discharged from the Emergency Department or following an observational admission since their symptoms have resolved. Some portion of these patients, however, return to the hospital due to various reasons. The aim of our study is to find the trend of TIA readmissions in the United States. Materials and Methods: Using the Healthcare Cost and Utilization Project (HCUP) database, we analyzed TIA discharges and TIA readmissions between 2009-2014 using the statistical z-test. Results and Statistical Analysis: We recorded a total of 985,851 hospitalizations of patients discharged with TIA with a significant decrease from 2009 to 2014 (p<0.001). Patients had a mean age of 70.4 years and were mainly women (58.43%, P<0.01). HCUP reported 34,503 discharges due to TIA readmissions within 7 days (3.73%) and 91,261 discharges due to readmissions within 30 days (9.83%); both values showed a significant decrease during the study period. Summation of the TIA readmissions found that acute cerebrovascular disease was the leading cause of readmission, followed by another TIA in both seven and thirty days. Conclusion: Between 2009-2014 the rate of TIA and TIA readmissions has significantly decreased in the United States, especially in the female gender. Acute cerebrovascular disease and another TIA have been the leading cause of hospital readmissions. With a better understanding of the risk factors associated with hospital readmissions, it is possible to reduce the impending burden of these patients on the healthcare system.

P469Minimally interrupted versus uninterrupted non-vitamin K anticoagulants for atrial fibrillation ablation. a meta-analysis of randomized controlled trials

Abstract Introduction More and more patients undergoing atrial fibrillation (AF) ablation are anticoagulated with direct oral anticoagulants (DOAC). In order to balance the peri-procedural risk of bleeding with the risk of stroke, an important clinical question is whether to continue an interrupted DOAC administration or minimal interrupt by skipping the last one or two doses before the procedure. Dealing with rare events, the randomized controlled trials (RCTs) looking at this question have not been sufficiently powered to give a definitive answer. Purpose To do a systematic review of the literature comparing an uninterrupted DOAC strategy to minimally interrupted (1-2 doses) strategy in the setting of AF ablation in terms of peri-procedural stroke and bleeding. Methods PubMed, EMBASE, and Cochrane databases were searched for RCTs comparing a strategy of uninterrupted versus minimally interrupted DOAC administration for atrial fibrillation ablation. The primary endpoint was a composite of clinically significant adverse events: ischemic stroke, transient ischemic attack (TIA), systemic embolism, and major or minor bleeding events. A random-effects meta-analysis was performed on the resulting trials. The systematic review protocol was pre-registered in the PROSPERO database. The study selection process followed the PRISMA statement. Results After checking and removing duplicates, 188 articles were screened by reading the title and abstract. 8 of them were selected for a full text screening. Because 3 were not randomized, finally, 5 RCTs met the inclusion criteria. A total of 1 769 patients were included in the meta-analysis, and the sample size of the individual RCTs ranged from 97 to 846 patients. The overall prevalence of paroxysmal AF varied from 54% to 100%. The mean age of patients ranged from 63,5 to 70 years, and 21,6% to 32,8% of the trial populations were women. Comorbidities, such as hypertension, dyslipidemia, and diabetes, were common. Most patients had CHA2DS2-VASc &amp;lt; 3; range from 1,7 to 2,7We found consistently low rates of strokes, TIAs, systemic embolisms and bleedings across all trials and both arms (RR = 0.98, 95% CI 0.69 – 1.38, I-squared = 0%, p = 0.874). Conclusion We found no evidence in favor of a difference between uninterrupted and interrupted administration of NOACs regarding the primary outcome of clinical thromboembolic and bleeding. Abstract Figure. Meta-analysis of the primary outcome

Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting

Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P=0.0236). Although the individual outcome of death occurred less often in TCAR (P=0.0025), there was no difference in the occurrence of in-hospital stroke (P=0.8836) or TIA (P=0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P=0.0062). A worse outcome was associated with increasing age (P<0.001), a prior stroke (P<0.0001), and increasing number of stents (P=0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P=0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P=0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P=0.6158), there were significantly fewer strokes in those treated with TCAR (P=0.0132). TCAR (P=0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P=0.0003), prior strokes (P=0.01), and a left-sided lesion (P=0.0176). TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.

Protamine use in transcarotid artery revascularization is associated with lower risk of bleeding complications without higher risk of thromboembolic events

ObjectiveRecent studies have found that transcarotid artery revascularization (TCAR) is associated with lower risk of stroke or death compared with transfemoral carotid artery stenting but higher risk of bleeding complications, presumably associated with the need for an incision. Heparin anticoagulation is universally used during TCAR, so protamine use may reduce bleeding complications. However, the safety and effectiveness of protamine use in TCAR are unknown. We therefore evaluated the impact of protamine use on perioperative outcomes after TCAR in the Vascular Quality Initiative TCAR Surveillance Project. MethodsWe performed a retrospective review of patients undergoing TCAR in the Vascular Quality Initiative TCAR Surveillance Project from September 2016 to April 2019. We assessed in-hospital outcomes using propensity score-matched cohorts of patients who did and did not receive protamine. The primary efficacy end point was access site bleeding complications, and the primary safety end point was in-hospital stroke or death. Secondary end points included the individual end points of stroke, death, transient ischemic attack, myocardial infarction, congestive heart failure exacerbation, and hemodynamic instability. ResultsOf the 5144 patients undergoing TCAR, all patients received heparin and 4072 (79%) patients received protamine. We identified 944 matched pairs of patients who did and did not receive protamine. Protamine use was associated with a significantly lower risk of bleeding complications (2.8% vs 8.3%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.21-0.52; P < .001), including bleeding that resulted in interventional treatment (1.0% vs 3.6%; RR, 0.26; 95% CI, 0.13-0.54; P < .001) and in blood transfusion (1.2% vs 3.9%; RR, 0.30; 95% CI, 0.15-0.58; P <.001). There were no statistically significant differences in in-hospital stroke or death for patients who received protamine and those who did not (1.6% vs 2.2%; RR, 0.71; 95% CI, 0.37-1.39; P = .32); however, there was a trend toward lower risk of stroke for patients who received protamine (1.1% vs 2.0%; RR, 0.53; 95% CI, 0.24-1.13; P = .09). There were also no statistically significant differences in the rates of transient ischemic attack (0.4% vs 1.1%; RR, 0.40; 95% CI, 0.13-1.28; P = .11), myocardial infarction (0.4% vs 0.8%; RR, 0.50; 95% CI, 0.15-1.66; P = .25), heart failure exacerbation (0.4% vs 0.3%; RR, 1.33; 95% CI, 0.30-5.96; P = .71), or postoperative hypotensive hemodynamic instability (16% vs 15%; RR, 1.06; 95% CI, 0.83-1.35; P = .50) with protamine use. ConclusionsProtamine can be safely used in TCAR to reduce the risk of perioperative bleeding complications without increasing the risk of thrombotic events.