Relative Risk Of Ischemic Stroke Research Articles

Abstract WP229: Comparing the Real-World Effects of Once-Weekly Semaglutide and Dipeptidyl Peptidase-4 Inhibitors on Cardiovascular Outcomes, Health Care Resource Utilization, and Medical Costs in Individuals With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease

When compared with placebo, glucagon-like peptide-1 receptor agonists such as once-weekly semaglutide (semaglutide OW T2D) improve cardiovascular outcomes in people with type 2 diabetes (T2D), whereas dipeptidyl peptidase-4 inhibitors (DPP-4is) do not. However, no head-to-head trials of these 2 incretin-based drug classes have been conducted. This retrospective cohort study used 2018-2022 data from the Optum ® Clinformatics ® Data Mart to compare on-treatment time with incidence of ischemic stroke, myocardial infarction (MI), and 2-point major adverse cardiovascular events (MACE; composite of ischemic stroke and MI); health care resource utilization; and medical costs in new adult users of semaglutide OW T2D and DPP-4is with T2D and atherosclerotic cardiovascular disease (ASCVD). Patients were followed until drug discontinuation, enrollment end, or an event. Baseline characteristics ( Table ) were balanced using inverse probability of treatment weighting. On average, patients were aged 70 years, with 5.6- and 4.3-year history of T2D and ASCVD, respectively. Survival analyses were conducted to compare risks during exposure. Users of semaglutide OW T2D (weighted n=14,461) had 46%, 36%, and 40% lower relative risk of ischemic stroke, MI, and 2-point MACE, respectively, compared with users of DPP-4is (weighted n=38,630; all P ≤0.001; Figure ). Users of semaglutide OW T2D also had decreased ASCVD-related and all-cause hospitalizations, outpatient visits, hospitalization costs, and total medical costs (all P <0.05). This study suggests that semaglutide OW T2D reduces the risk of stroke and MI while reducing medical costs relative to DPP-4is in adults with T2D and ASCVD.

Change in incidence of ischemic stroke and mortality among patients with atrial fibrillation over a period of 30 years, a nationwide, register-based cohort study

Abstract Background During the last decades we have faced large changes in lifestyle and cardiovascular risk factor patterns, as well as screening and treatment advances of patients with atrial fibrillation (AF). Aim To investigate trends in ischemic stroke (IS) and mortality in Sweden over a period of 30 years among patients with AF and compare it to matched controls without AF. Methods This is a Swedish nationwide registry-based retrospective case-control study of patients diagnosed with AF combining data from National Patient Register (NPR) and Cause of Death Register between 1987 and 2018. Controls were defined as Swedish inhabitants without AF and matched by age, sex and county. With the use of international classification of diseases (ICD) 9- and 10- codes we identified all patients diagnosed with AF, and comorbidities at baseline from NPR. Results In total, we identified 739,388 patients with AF and 1,386,448 matched controls. The mean age of the study population was 78.8 (12.6); and (46.2%) were female. Cochran-Armitage test showed a significant increase of all comorbidities over time, except for myocardial infarction for patients and PAH för controls. The Incidence rate for IS per 1000 person-year within one year declined from 40.9 (95% C.I.: 30.1-55.6) in 1987 to 16.2 (95% C.I.: 9.9-26.4) in 2017 (p <.0001) for patients with AF and from 12.2 (95% CI: 7.0-21.4) in 1987 to 6.2 (95% CI: 2.8-13.7) in 2017 (p <.0001) in controls. The prescription of oral anticoagulant therapy (OAK) increased from 40% in 2006 to almost 80% in 2018. The total 1-year mortality rate of IS was at 175.4 (151.3-203.4) for AF cases and 58.3 (45.1-75.4) for controls (p<0001). Compared to controls and adjusted for age, sex and comorbidities patients had HR for IS at 3.01 (95% CI: 2.89-3.13) between 1987 and 1999 that decreased to HR 2.75 (95% CI: 2.63-2.88) between 2010 and 2017 in patients with AF. After adjustment for baseline comorbidities and OAK the one-year risk for IS decreased from HR 1.01 (95% CI: 0.95-1.08) in 2012 to 0.41 (95% CI: 0.36-0.47) in patients and HR 0.50 (95% CI: 0.43-0.58) in 2012 to 0.37 (95% CI: 0.31-0.43) in controls, respectively (both p<0.0001). Conclusions This study revealed significant prognostic improvement of patients with AF showing decrease in the incidence rate and relative risk for IS, as well as all-cause mortality within one year of AF diagnose. The prescription of OACs almost doubled between 2006 and 2018 in patients with AF and was associated with a significant decrease of the relative risk for IS to almost same level as in controls without AF.

Time trends in atrial fibrillation-related stroke during 2001-2020 in Sweden: a nationwide, observational study.

Great efforts have been made to improve stroke prevention in atrial fibrillation (AF) patients. Meanwhile, incidence of AF is increasing, which may affect the share of AF-related stroke on all strokes. We aimed to examine the temporal trends in the incidence of AF-related ischemic stroke between 2001 and 2020, if it varied by use of novel oral anticoagulant drugs (NOAC), and if the relative risk of ischemic stroke associated with AF changed over time. Data from the total Swedish population aged ≥70 years during the period 2001-2020 were used. Annual incidence rate (IR) was calculated for overall and AF-related ischemic stroke which was defined as first-ever ischemic stroke with AF diagnosed up to 5 years before, on the same day, or within 2 months after the stroke event. Cox regression models were performed to examine if the hazard ratio (HR) between AF and stroke changed over time. While IR of ischemic strokes declined during 2001-2020, IR of AF-related ischemic stroke remained stable between 2001 and 2010 but showed a consistent decline between 2010 and 2020. The HR of ischemic stroke within 3 years from an AF diagnosis came down from 2.39 (95% confidence interval: 2.31-2.48) to 1.54 (1.48-1.61) over the study period, which was largely explained by a substantial increase in the use of NOAC among AF patients after 2012. Yet, by the end of 2020, 24% of all ischemic strokes had a preceding or concurrent AF diagnosis, which is slightly higher than in2001. Even though both the absolute and relative risk of AF-related ischemic stroke declined over the past 20 years, every fourth ischemic stroke in 2020 still had a preceding or concurrent AF diagnosis. This represents a great potential for future gains in stroke prevention among AF patients. Swedish Research Council and Loo and Hans Osterman Foundation for Medical Research.

Assessment of Low-Level Air Pollution and Cardiovascular Incidence in Gdansk, Poland: Time-Series Cross-Sectional Analysis.

(1) Background: More than 1.8 million people in the European Union die every year as a result of CVD, accounting for 36% of all deaths with a large proportion being premature (before the age of 65). There are more than 300 different risk factors of CVD, known and air pollution is one of them. The aim of this study was to investigate whether daily cardiovascular mortality was associated with air pollutants and meteorological conditions in an urban environment with a low level of air pollution. (2) Methods: Data on daily incidence of strokes and myocardial infarctions in the city of Gdansk were obtained from the National Health Fund (NHF) and covered the period from 1 January 2014 to 31 December 2018. Data on the level of pollution, i.e., SO2, NO, NO2, NOx, CO, PM10, PM2.5, CO2, O3 and meteorological conditions came from the foundation: Agency of Regional Air Quality Monitoring in the Gdańsk metropolitan area (ARMAG). Using these data, we calculated mean values with standard deviation (SD) and derived the minimum and maximum values and interquartile range (IQR). Time series regression with Poisson distribution was used in statistical analysis. (4) Results: Stroke incidence is significantly affected by an increase in concentrations of NO, NO2 and NOx with RRs equal to 1.019 (95%CI: 1.001-1.036), 1.036 (95%CI: 1.008-1.064) and 1.017 (95%CI: 1.000-1.034) for every increase in IQR by 14.12, 14.62 and 22.62 μg/m3, respectively. Similarly, myocardial infarction incidence is significantly affected by an increase in concentrations of NO, NO2 and NOx with RRs equal to 1.030 (95%CI: 1.011-1.048), 1.053 (95%CI: 1.024-1.082) and 1.027 (95%CI: 1.010-1.045) for every increase in IQR by 14.12, 14.62 and 22.62 μg/m3, respectively. Both PM10 and PM2.5 were positively associated with myocardial infarction incidence. (5) Conclusions: In this time-series cross-sectional study, we found strong evidence that support the hypothesis that transient elevations in ambient PM2.5, PM10, NO2, SO2 and CO are associated with higher relative risk of ischemic stroke and myocardial infarction incidents.

Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation.

While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin. This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death. Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users. Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.

NO CLOT, NO PROBLEM? NOT EXACTLY

NO CLOT, NO PROBLEM? NOT EXACTLY

Increased Risk of Ischemic Stroke Amongst Patients with Primary Autoimmune Hemolytic Anemia in Denmark and France

▪IntroductionAn increased risk of thromboses has been described in patients with autoimmune hemolytic anemia (AIHA), including stroke. Previous studies focused on a broad variety of autoimmune disorders and only adjusted to a limited extent for potential confounders. Further, these studies could not robustly address the relationship of stroke risk with time since AIHA diagnosis. To overcome these shortcomings, we conducted a study of the risk of ischemic stroke amongst patients with primary AIHA in two nationwide cohorts in Denmark and France.MethodWe identified all patients 15+ years of age diagnosed with primary AIHA in the Danish National Patient Register (1996-2016) and the French health insurance database, Système National des Données de Santé (2012 - 2017). At AIHA diagnosis, patients were age- and sex-matched to comparison cohorts from the general populations in Denmark (1:50) and France (1:5), respectively. Each patient's date of diagnosis was allotted to their corresponding comparisons and marked the start of a 5-year follow-up of the cohorts. We linked data on the cohorts to information from national registers concerning (co)morbidity, vital status and outcomes. Based on this data, we identified comorbidities at baseline (including preexisting cardiovascular and cerebrovascular events (CVD) at diagnosis) and ischemic stroke events during follow-up.We evaluated the absolute risk of ischemic stroke using cumulative incidences, treating death and migration as competing events. Further, the relative risk of ischemic stroke was evaluated using unadjusted cause-specific proportional hazard regression (csHR) and Fine-Gray subdistribution HR (subHR), and subsequently adjusting for CVD event history, atrial fibrillation, diabetes, hypertension, dyslipidemia, history of venous thromboembolism, cancer, and time-varying exposure to antiplatelet, anticoagulant, lipid lowering, and antihypertensive drugs. HRs were estimated both overall for all five years and for the first year after diagnosis for the two countries separately. Hazard ratios for the data from both countries combined were also computed using meta-analysis techniques.ResultsWe included 1,171 (Denmark) and 4,823 (France) patients with primary AIHA and 57,773 (Denmark) and 23,752 (France) comparisons from the general population. During follow-up, 35.1% (Denmark) and 38.3% (France) of patients with AIHA died.Age, gender, and comorbidity distribution as well as mortality was similar in the two countries. Similar differences in the prevalence of previous CVD events were observed between AIHA patients (higher prevalence of CVD) and comparison cohorts in both countries.We identified 29 (Denmark) and 92 (France) ischemic stroke events amongst patients with AIHA, of whom 12 (Denmark) and 57 (France) occurred during the first year after AIHA diagnosis.The cumulative stroke incidences are depicted in the Figure (Panel A: French cohort. Panel B: Danish cohort).Overall, the combined adjusted csHR was 1.3 [1.1; 1.6], and the subHR was 1.0 [0.9; 1.2].Within the first year from diagnosis, the combined adjusted csHR was 2.3 [1.8; 2.9], and the subHR was 1.7 [1.3; 2.2].Discussion and conclusionIn a combined Danish-French cohort of 5.994 patients with primary AIHA and 81.525 comparisons, we confirm that the risk of ischemic stroke amongst patients with primary AIHA is increased.The risk is highest within the first year after diagnosis with a csHR of 2.3 and a subHR of 1.7. This indicates that although the risk of ischemic stroke is high among patients with primary AIHA compared to the general population, the effect on the cumulative incidence of ischemic stroke is diminished by competing events - especially death.Granular data on treatment was not generally available and our data does not allow us to infer whether the increased risk of ischemic stroke in AIHA derives from the hemolytic process, the treatment or other factors. However, as the risk was highest within the first year and as prior thromboembolic and vascular events were more prevalent amongst patients this could support the hypothesis that free hemoglobin leads to endothelial dysfunction and a procoagulant state that also increases the risk of stroke. [Display omitted] DisclosuresHansen: Novartis: Research Funding; Alexion: Research Funding. Berentsen: True North Therapeutics: Consultancy; Sanofi: Consultancy, Honoraria; Janssen-Cilag: Honoraria; Bioverativ: Consultancy, Honoraria; Mundipharma: Research Funding; Apellis Pharmaceuticals: Consultancy, Honoraria; Alexion Pharmaceuticals, Inc: Honoraria. Frederiksen: Novartis: Research Funding; Alexion: Research Funding; Gilead: Research Funding; Abbvie: Research Funding; Janssen Pharmaceuticals: Research Funding. Moulis: Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Argenix: Membership on an entity's Board of Directors or advisory committees; Grifols: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sobi: Membership on an entity's Board of Directors or advisory committees.

Migraine with aura.

Around 15% to one-third of migraineurs experience aura. Aura is a fully reversible focal neurological phenomenon involving visual, sensory, speech, and/or motor symptoms that develops gradually and usually precedes the headache phase. The pivotal role of cortical spreading depression (CSD) as a mechanism underlying aura has been widely supported by a large body of studies. The diagnosis is based on the International Headache Classification Disorders III edition criteria. Aura is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features, and complete reversibility. Visual aura is the most common type of aura, occurring in over 90% of patients. When aura symptoms are multiple, they usually follow one another in succession, beginning with visual, then sensory, then aphasic; but the reverse and other orders have been noted. The accepted duration for most aura symptoms is one hour, but motor symptoms, which are rare, are often longer lasting. When a patient experiences for the first time a possible aura phase it's sometimes difficult to know if there was gradual or brutal onset of the symptoms. If the patient has no visual aura symptoms or simultaneous neurological symptoms, or presents neurological symptoms corresponding to a cerebral vascular territory, emergency exploration of a possible transient ischemic attack is necessary. Long duration (greater than one hour) of what may or may not be an aura phase, late onset of aura, or a dramatic increase in aura attacks should also be explored. The relative risk of ischemic stroke is significantly increased in migraine with aura. Combined hormonal contraception with estrogens significantly increases the risk of stroke in women with migraine with aura. It is recommended to start non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin as soon as possible during the aura phase, not to treat the aura, but to avoid or to diminish the headache phase. In case of failure of NSAIDs or aspirin it is recommended to use a triptan when the headache begins. The prophylactic treatments for migraine with aura are those used in migraine without aura based on very few randomized clinical trials specifically dedicated to migraine with aura.

Incidence of Ischemic Stroke in Individuals With and Without Aortic Valve Stenosis: A Danish Retrospective Cohort Study.

Background and Purpose- Aortic valve stenosis may lead to atrial and ventricular remodeling, predisposes to atrial fibrillation, and may also be an independent risk factor of ischemic stroke. However, information on stroke rates among persons with aortic valve stenosis are sparse. We aimed to determine the incidence rates and relative risks of ischemic stroke in individuals with diagnosed aortic valve stenosis compared with age- and sex-matched controls. Methods- All patients with incident aortic valve stenosis aged >18 years (n=79 310) and age- and sex-matched controls were identified using the Danish nationwide registries (1997-2017). Incidence rates per 1000 person-years (PY) and multivariable adjusted hazard ratios with 95% CIs were reported. Results- In total, 873 373 individuals (median age 77 years, 51.5% men, 9.1% with aortic valve stenosis) were included. Ischemic stroke occurred in 70 205 (8.0%) individuals during 4 880 862 PY of follow-up. Incidence rates of ischemic stroke were 13.3/1000 PY among the controls compared with 30.4/1000 PY in patients with aortic valve stenosis, corresponding to a hazard ratio of 1.31 (95% CI, 1.28-1.34). In all age-groups, the incidence rates and relative risks were significantly increased in patients with aortic valve stenosis compared with controls, but the relative risk was greater for younger individuals (eg, age group, 18-45 years: hazard ratio, 5.94 [95% CI, 4.10-8.36]). In patients with aortic valve stenosis above 65 years of age, the risk of ischemic stroke was markedly lower after aortic valve replacement (30.3 versus 19.6/1000 PY before and after valve replacement). Among people with atrial fibrillation the incidence rate of ischemic stroke was 1.5 times higher when aortic valve stenosis was present (33.0/1000 PY versus 49.9/1000 PY). Conclusions- People with aortic valve stenosis have a significantly increased risk of ischemic stroke compared with age- and sex-matched controls. Future studies are warranted to explore whether antithrombotic therapy may be beneficial in some individuals.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk.

Background and Purpose- Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods- We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results- The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions- A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Asthma, asthma control and risk of ischemic stroke: The HUNT study

BackgroundAsthma, a chronic inflammatory airway disease, shares common pathophysiological mechanisms with ischemic stroke. The aim of the study is to assess the association between asthma, levels of asthma control and ischemic stroke risk in men and women and by smoking habits. MethodsThis prospective population-based cohort study utilized data on 58 712 adults from HUNT Study in Norway free from stroke. Self-reported asthma was categorized as ever asthma, non-active asthma and active asthma (i.e., being on asthma medication within 12 months of the baseline). Asthma control was defined according to the Global Initiative for Asthma questionnaire and was categorized into controlled and not controlled asthma. Stroke was ascertained by linking HUNT data with Nord-Trøndelag hospital records and the Norwegian Patient Registry. ResultsDuring a mean follow-up of 17.3 ± 5.3 years, 2619 participants (4.5%) had a first stroke. Not controlled asthma was associated with a modest increased risk of stroke (adjusted HR 1.34, 95%CI 1.03–1.73). Subgroup analyses revealed that the respective association was stronger among those with history of smoking (HR 1.48, 95%CI 1.10–2.00) and males (HR 1.55, 95%CI 1.12–2.16) while absent in non-smokers (HR 1.02, 95%CI 0.61–1.70) and females (HR 1.05, 95%CI 0.69–1.60). Likewise, active asthma was associated with similar increased stroke risk among smokers and males and absent in non-smokers and females. ConclusionsSymptomatic and active asthma was associated with a modest increased relative risk for ischemic stroke in smokers and males. Future studies should clarify the difference in risks and mechanisms between different phenotypes of asthma.

Risk of ischemic stroke in patients with hypertrophic cardiomyopathy in the absence of atrial fibrillation - a nationwide cohort study.

Ischemic stroke (IS) is a catastrophic complication of hypertrophic cardiomyopathy (HCM) with aging. We investigated the incidence of IS in HCM patients without atrial fibrillation (AF) and compared the relative risk of IS with matched general population with AF. This study identified 17,371 HCM patients without AF and utilized propensity-score-matching to identify one-to-one matched control of general population with AF receiving oral anti-coagulants (OACs). During a median follow-up of 7.3 years, 847 (4.9%) subjects experienced IS with the incidence of 0.589/100 person-years. The corresponding matched controls experienced 788 (4.5%) events with the incidence of 0.494/100 person-years. Compared with control, HCM patients had similar risk of IS (Hazard ratios [HRs] 0.965, 95% confidence interval [CI] 0.854-1.091). HCM patients with age above 65 years had a significantly increased risk of IS (age 65-74 years, HR 1.278, 95% CI 1.070-1.335; age ≥75 years, HR 1.757, 95% CI 1.435-2.152). Stratified by CHA2DS2-VASc score, HCM subjects with score 0, 1 and 2 had significantly increased risk of IS than control while those with score ≥2 had similar risk as control. Compared with general population with AF, HCM patients without AF had similar risk of IS, suggesting OACs might be necessary in HCM patient without AF.

P668Aspirin for primary prevention of cardiovascular disease

Abstract Background Platelet inhibition by aspirin reduces ischemic events but increases the risk of bleeding events. Yet, the role of aspirin in primary prevention of cardiovascular disease remains unclear. Purpose To produce a clinically relevant benefit-risk assessment of aspirin for primary prevention of cardiovascular disease. Methods We performed a meta-analysis of aspirin effects in primary prevention of cardiovascular disease comprising 13 randomized-controlled trials in 164.225 patients comparing aspirin versus placebo/control during a mean follow-up period of 6.4 years. Using a random effect model, relative risks and 95% confidence intervals were calculated for each outcome. Results Aspirin reduced the relative risk of ischemic stroke by 10% (RR: 0.90; 95% CI: 0.82–0.99), myocardial infarction by 14% (RR: 0.86; 95% CI: 0.77–0.95) and the major adverse cardiovascular events by 9% (RR: 0.91; 95% CI: 0.86–0.95) but was associated with a 46% relative risk increase of major bleeding events (RR: 1.46; 95% CI: 1.30–1.64). Aspirin did not reduce the risk of cardiovascular mortality (RR: 0.99; 95% CI: 0.90–1.08), all-cause mortality (RR: 0.98; 95% CI: 0.93–1.02) or cancer (RR 1.05; 95% CI, 0.87–1.26). Aspirin use did not translate into a net clinical benefit adjusted for event-associated mortality risk (mean 0.034%; 95% CI: −0.18 to 0.25%). Forest plot of major outcomes. Conclusions Aspirin use in primary prevention is associated with a reduced risk of stroke and myocardial infarction, but at a cost of an increased risk of major bleeding. Acknowledgement/Funding None

Novel anticoagulants versus vitamin K antagonists for cardioversion of non- valvular atrial fibrillation \u2013 a meta-analysis of more than 17000 patients

Non-vitamin K antagonist oral anticoagulants (NOACs) have proven a favorable risk-benefit profile compared to vitamin K antagonists (VKAs) for preventing stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF), but actual data are not sufficiently powered to extend this profile on patients with AF that undergo cardioversion. We aimed to compare outcomes after cardioversion of AF under NOACs vs. VKAs. We systematically searched Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies published until October 2017. A total of 17506 patients from 11 studies were included. Treatment with NOACs was associated with similar relative risks (RR) of stroke and systemic embolism, hemorrhagic stroke, myocardial infarction, cardiovascular death, and all cause death compared to VKAs treatment. The RR of ischemic stroke was lower in the NOACs group. The risk of major bleeding was similar across treatment groups. Treatment with NOACs in patients with non-valvular AF that undergo cardioversion seems to be as safe and effective as the use of classical VKAs, with a better profile for ischemic stroke. Clinical Trial Registration: PROSPERO Registry, CRD42018086181 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID = 86181.

Dose-Response Relationship Between Thrombin-Activatable Fibrinolysis Inhibitor (TAFI) and Stroke: A Chinese Case-Control Study.

BackgroundBecause TAFI (thrombin-activatable fibrinolysis inhibitor) antigen varies widely among different populations, we performed this case-control study to explore the relationship between TAFI levels and stroke in a Chinese population.Material/MethodsOur population-based case-control study included 217 stroke patients and 218 healthy controls. The plasma TAFI level was measured by immune turbidimetry. Univariate and multivariate logistic regression analyses were used to analyze the association between different TAFI levels and stroke and its subtypes. Restricted cubic spline (RCS) combined with logistic regression analysis were used to explore the dose-response relationship between TAFI levels and stroke.ResultsThe plasma TAFI levels of cases were much higher than in the control group (p=0.038) and this difference persisted even after adjustment (OR=2.2). In the elderly (aged over 60) and female subgroups, TAFI levels in stroke patients were higher than those in controls, and the results were also noted in ischemic stroke. The dose-response curve showed that, as a whole, with the increase of TAFI levels, the relative risk of stroke first increased and then decreased (p=0.0127). Similarly, in general, with the increase of TAFI levels, the curve showed that the relative risk of ischemic stroke first increased and then decreased (p=0.0110).ConclusionsThere was a definite correlation between TAFI levels and stroke in this Chinese population, and with the increase of TAFI levels, the relative risk of stroke or ischemic stroke first increased and then decreased.

Stroke in systemic lupus erythematosus: a Swedish population-based cohort study

ObjectiveTo study the occurrence of ischaemic and haemorrhagic stroke in systemic lupus erythematosus (SLE) compared with the general population by age, sex and time since SLE diagnosisMethodsAdults with incident SLE...

Female- and Male-Specific Risk Factors for Stroke

The incidence of stroke is higher in men than in women. The influence of sex-specific risk factors on stroke incidence and mortality is largely unknown. To conduct a systematic review and meta-analysis of female- and male-specific risk factors for stroke. PubMed, EMBASE, and the bibliographies of articles were searched for studies published between January 1, 1985, and January 26, 2015, reporting on the association between female- and male-specific characteristics and stroke. Observational studies reporting associations between sex-specific risk factors and stroke were selected. Two authors performed data extraction independently. Estimates were pooled with a generic variance-based, random-effects method. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. In addition, our study adhered to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Ischemic stroke, hemorrhagic stroke, any stroke, and stroke mortality. This systematic review and meta-analysis included 78 studies (70 longitudinal and 8 case-control) comprising 10 187 540 persons. In women, the pooled relative risks of ischemic stroke were 1.80 (95% CI, 1.49-2.18) after any hypertensive disorder in pregnancy (HDP) (gestational hypertension [GH], preeclampsia, or eclampsia) and 1.81 (95% CI, 1.44-2.27) after GH vs no HDP. The pooled relative risks of hemorrhagic stroke were 2.24 (95% CI, 1.19-4.21) in women with menopause at the age of at least 55 years vs 50 to 54 years and 5.08 (95% CI, 1.80-14.34) after GH vs no GH. The pooled relative risks of any stroke were 1.42 (95% CI, 1.34-1.50) after oophorectomy vs no oophorectomy, 0.88 (95% CI, 0.85-0.90) after hysterectomy vs no hysterectomy, 1.63 (95% CI, 1.52-1.75) after any vs no HDP, 1.54 (95% CI, 1.39-1.70) after preeclampsia or eclampsia, 1.51 (95% CI, 1.27-1.80) after GH vs no HDP, 1.62 (95% CI, 1.46-1.79) after preterm delivery, and 1.86 (95% CI, 1.15-3.02) after stillbirth vs no pregnancy complications. The pooled relative risk of stroke mortality was 1.57 (95% CI, 1.04-2.39) after GH vs no GH. In men, the pooled relative risks of ischemic stroke were 1.19 (95% CI, 1.05-1.34) after androgen deprivation therapy (ADT) vs no ADT and 1.21 (95% CI, 1.00-1.46) after orchiectomy vs no orchiectomy. The pooled relative risks of any stroke were 1.21 (95% CI, 1.06-1.37) for ADT vs no ADT and 1.35 (95% CI, 1.18-1.53) for erectile dysfunction vs no dysfunction. Female-specific characteristics increasing stroke risk include HDP for ischemic stroke, late menopause and gestational hypertension for hemorrhagic stroke, and oophorectomy, HDP, preterm delivery, and stillbirth for any stroke. Hysterectomy is possibly protective against any stroke. Male-specific characteristics increasing stroke risk include medical androgen deprivation therapy for ischemic and any stroke and erectile dysfunction for any stroke. Consideration of sex-specific risk factors can improve individualized stroke risk assessment.

Is There an Increased Risk for Ischemic Stroke in Patients with Multiple Sclerosis, and If So, Should Preventive Treatment Be Considered?

Is There an Increased Risk for Ischemic Stroke in Patients with Multiple Sclerosis, and If So, Should Preventive Treatment Be Considered?

Subtotal Gastrectomy With Billroth II Anastomosis Is Associated With a Low Risk of Ischemic Stroke in Peptic Ulcer Disease Patients: A Nationwide Population-Based Study.

Duodenal diversion can ameliorate lipid and glucose metabolism. We assessed the risk of stroke after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) in peptic ulcer disease (PUD). We identified 6425 patients who received SGBIIA for PUD between 1998 and 2010 from the Taiwan National Health Insurance Research Database as the study cohort; we frequency-matched them with 25,602 randomly selected controls from the PUD population who did not receive SGBIIA according to age, sex, index year, and comorbidities including hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and obesity. All patients were followed until the end of 2011 to determine the incidence of stroke. The incidence of stroke was lower in patients in the SGBIIA cohort than in those in the non-SGBIIA cohort (18.9 vs 22.9 per 1000 person-years, adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.72-0.89, P < 0.001). The risk of ischemic stroke (aHR 0.77, 95% CI 0.69-0.86, P < 0.001), rather than hemorrhagic stroke (aHR 1.00, 95% CI 0.78-1.28), was lower for the SGBIIA cohort than for the non-SGBIIA cohort according to the multivariable Cox proportional hazard regression analysis. The relative risk of ischemic stroke after SGBIIA was lower in men (aHR 0.77, 95% CI 0.69-0.86) than in women (aHR 0.80, 95% CI 0.65-0.99) and in patients aged ≥65 years (aHR 0.72, 95% CI 0.63-0.81) than in those of other age groups (≤49 years, aHR 0.82, 95% CI 0.48-1.39; 50-64 years, aHR 1.01, 95% CI 0.79-1.28). The relative risk of ischemic stroke after SGBIIA was also reduced in patients with comorbidities (aHR 0.84, 5% CI 0.75-0.95) rather than in those without comorbidities (aHR 0.81, 95% CI 0.59-1.12). SGBIIA is associated with a low risk of ischemic stroke for PUD patients, and its protective effect is prominent in men, patients aged ≥65 years, and those with comorbidities.

Apolipoprotein A1, B levels, and their ratio and the risk of a first stroke: a meta-analysis and case–control study

The associations of levels of apolipoprotein A1 (ApoA1) and apolipoprotein B and ApoB/A1 ratio and risk of a first stroke have not been reliably documented. We performed a meta-analysis to summarize the relationships and confirmed them in a case-control study. We identified relevant publications in PubMed and Embase databases up to June 1, 2015. A Dersimonian-Laird random effects model was used to compute summary relative risks (RRs) and 95 % confidence intervals (CIs). A case-control study was conducted in a southern Chinese population. We included 8 cohort and 4 case-control studies (222,774 subjects; 10,032 first stroke events) in the meta-analysis. Reduced ApoA1 level and increased ApoB level and ApoB/A1 ratio was associated with a first stroke in cohort studies (RR 0.86 [95 % CI 0.79-0.94], 1.66 [1.62-1.69], and 1.66 [1.63-1.70], respectively) and reduced ApoA1 level and increased ApoB/A1 ratio in case-control studies (0.68 [0.47-0.99] and 1.76 [1.50-2.06], respectively). When stratified by stroke type in cohort studies, the RR for ischemic stroke was 0.83 (0.76-0.90), 1.36 (1.32-1.40), and 1.38 (1.35-1.42) for the 3 factors, respectively. In our case-control study (1013 cases; 1029 controls), the OR for a first ischemic stroke was 0.83 (0.74-0.92), 1.33 (1.18-1.48) and 2.10 (1.76-2.51), respectively, with increased ApoA1 level associated with hemorrhagic stroke (1.37 [1.06-1.78]). Meta-analysis suggests that reduced ApoA1 level and increased ApoB level and ApoB/A1 ratio are risk factors for a first ischemic but not hemorrhagic stroke. Elevated ApoA1 level may be a risk factor for a first hemorrhagic stroke.