Risk Factor For Ischemic Events Research Articles

Cardiovascular risk factors in poly-vascular vs isolated lower extremity peripheral arterial disease. analysis from the SOLACI peripheral registry

Abstract Introduction Atherosclerotic disease in more than one vascular bed (Polyvascular disease), is a strong independent risk factor for ischemic events and has worse clinical outcomes than those with disease in a single territory. Aims The objective of the present interim analysis is to describe the differences in cardiovascular risk factors and clinical presentation between patients with isolated infra-aortic peripheral artery disease (lower limb: "LL-PAD") and patients with Polyvascular Disease ("PD": simultaneuous coexistence of LL-PAD and affection of at least one more vascular bed) from a cohort of patients undergoing LL endovascular procedures in Latinamerica. Methods Our cohort included patients from The SOLACI Peripheral Registry from March 2021 to February 2024 (a prospective, multi-center, observational, and hospital-based registry of patients with LL- PAD, treated with endovascular interventions across 10 Latin American countries, 42 centers). Patients were considered to have PD if besides LL-PAD, they had a documented history of previous myocardial infarction (MI), coronary revascularization, cerebrovascular, aortic, and/or carotid artery disease. Results A total of 1438 patients were included in the analysis. PD was present in 506 patients(35.1%), of which 225(44.5%) had previous MI; 296(58.5%) previous coronary revascularization;265(52.4%) had aortic and / or carotid disease; and 121(23.9%) had cerebrovascular disease. Patients with PD were older than those with LL-PAD(70.5±9.76 vs 68.6±10.7). PD was more prevalent in men(69.6% vs 62.4%), former smokers(48.2% vs 32.8%), hypertension(92.1% vs 80.5%) and patients with dyslipidemia(75.3% vs 64%). The distribution of treated lesions in the PD group was: 15.4% ilio-femoral; 34 % femoropopliteal; 23.3% infrapopliteal; and 24% had multiple peripheral territories affected and treated at the same time-point. In the LL-PAD group, the distribution of treated lesions was: 12.5% ilio-femoral; 28.6% femoropopliteal; 31.5% infrapopliteal; and 24.8% had multiple peripheral territories affected simultaneously and treated during the same procedure. In general, the lesions were shorter in the PD group: ilio-femoral(53.5±29.2 vs 66.7±48.2mm); femoropopliteal(119±73.6 vs 122±81.7mm); and infrapopliteal(129±83.1 vs 147±93.1mm). In the PD group, a higher percentage of patients were treated with statins and antithrombotic agents: statins (87.5% vs 70.8%), aspirin (91.5% vs 81.1%), clopidogrel (60.9% vs 40.1%), and oral anticoagulants (13.8% vs 6.5%). The use of rivaroxaban was similar in both groups (3.4% vs 3.9%). The PD group had higher intrahospital complication rates: intrahospital death (2.2% vs 0.8%), cardiovascular intrahospital death (1.2% vs 0.4%), MI (0.8% vs 0.1%), stroke (0.4% vs 0%) and bleeding (0.8% vs 0.9%). Conclusions Patients with PD represent a very high-risk population. Systematic screening of multiple vascular beds in patients with LL-PAD may be warranted to prevent worse outcomes.

Impact of glucose metabolism status on the relationship between remnant cholesterol and ischemic risk after percutaneous coronary intervention: a large-scale long-term cohort study from real-world

Abstract Background Elevated remnant cholesterol (RC) is considered a risk factor for ischemic events in patients with coronary artery disease (CAD). Recently evidence demonstrates a close connection between RC and cardiometabolic disorders, particularly diabetes mellitus (DM). However, it remains unclear whether different glucose metabolism statuses modify the association between RC and ischemic risk after percutaneous coronary intervention (PCI). Purpose This study aims to explore whether glucose metabolism statuses alter the relationship between RC and ischemic risk in CAD patients undergoing PCI. Methods This prospective study enrolled consecutive 10,724 CAD patients undergoing PCI throughout 2013. Patients were categorized into three groups: DM, pre-DM, and normal glucose regulation (NGR) group. Fasting RC was calculated as total cholesterol minus low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, and was analyzed based on tertile levels (low, middle, and high). The clinical endpoint was major adverse cardiovascular and cerebrovascular events (MACCE, including cardiac mortality, revascularization and stroke). Results A total of 9,406 PCI patients were ultimately included, among whom the average age was 58.44 ± 10.26 years and 2,142 (22.80%) were female. During 5-year follow-up, 1,876 (19.9%) patients experienced MACCE. In the overall cohort, the highest RC tertile was associated with a higher risk of MACCE (hazard ratio [HR]: 1.129, 95% confidence interval [CI]: 1.006-1.267) compared to those in the lowest tertile (Figure 1). Importantly, a significant interaction was observed between RC levels and glucose metabolism statuses (P for interaction = 0.032). In the DM group, multivariate Cox regression analysis revealed that the highest tertile of RC significantly increased a 1.172-fold risk of MACCE (HR:1.172, 95% CI:1.004-1.369). However, neither the pre-DM nor NGR groups showed any significant association between RC and MACCE (both P > 0.05). Further subgroup analysis found that the correlation between the highest tertile of RC and an increased MACCE risk was only in the DM group, which was prominent among females (Figure 2). Conclusions In a large-scale 5-year follow-up study, we are the first to demonstrate that RC-related ischemic risk may be exacerbated by diabetes in CAD patients undergoing PCI, highlighting the potential benefits of intensifying RC-lowering treatments for PCI patients combined with DM.

Correlation between lipoprotein(a) and recurrent ischemic events post-cerebral vascular stent implantation

Background and aimThe association of Lipoprotein(a) (Lp[a]) with recurrent ischemic events in stented patients remains uncertain. So, this research aimed to investigate the impact of elevated Lp(a) levels on the occurrence of ischemic events in this specific patient population. MethodsTotally 553 patients who underwent intracranial or extracranial artery stent implantation were included. Baseline data were collected and postoperative ischemic outcomes were followed up. Cox regression analysis was used to investigate the association between Lp(a) and outcomes, while accounting for confounding factors. Finally, we established prediction models based on nomogram. ResultsOf total 553 patients, a number of 107 (19.3%) experienced outcomes. These included 46 cases (25.4%) in group with elevated Lp(a) levels (>30 mg/dL) and 61 cases (16.4%) in non-elevated group (χ2=6.343, p=0.012). The group with elevated Lp(a) was 1.811 times more likely to experience ischemic events than the non-elevated group, each 1 mg/dL increase in Lp(a) resulted in a 1.008-fold increase in the recurrence rate of ischemic events. In addition, sex (male), previous history of coronary heart disease, decreased albumin, elevated very low density lipoprotein cholesterol and poorly controlled risk factors (including blood pressure and blood sugar) were also associated with a high risk of recurrent ischemic events after stent implantation. ConclusionLp(a) elevation was a significant risk factor for ischemic events in symptomatic patients who underwent intracranial or extracranial artery stenting.

The effects of CYP2C19 genotype polymorphism and clopidogrel resistance on ischemic event occurrence in patients with peripheral arterial disease undergoing revascularization: A prospective cohort study

IntroductionPeripheral arterial disease (PAD) affects approximately 236 million people worldwide. Therefore, this study aimed to investigate the relationship between CYP2C19 genotype polymorphisms and clopidogrel resistance (CR) following revascularization in patients with PAD. Materials and methodsIn total, 345 patients who underwent PAD revascularization were monitored for five years and risk factors for ischemic events were identified. Platelet reactivity and CYP2C19 genotypes were measured, and patients were classified as normal, intermediate, or poor metabolizers based on their genotypes. The study endpoint was defined as an ischemic event, that encompassed major adverse cardiovascular or limb events, or all-cause death. ResultsIn this study, ischemic events following PAD revascularization were associated with patient age, prior minor amputation, the Rutherford category before revascularization, indications for revascularization, index ankle-branchial index before revascularization, CYP2C19 phenotypes, and CR. Intermediate and poor metabolism, the Rutherford category before revascularization, and CR were independent risk factors for ischemic events in patients after PAD revascularization. Similarly, intermediate and poor metabolism, the Rutherford category before revascularization, and CR were independent risk factors for ischemic events in patients with PAD after revascularization within five years. Intermediate and poor metabolizers had a higher platelet reactivity and risk of CR than normal metabolizers. However, poor metabolizers had a higher platelet reactivity and risk of CR than intermediate metabolizers. Furthermore, the hazard ratio for ischemic events increased with platelet reactivity. This effect was more prevalent in intermediate and poor metabolizers than in normal metabolizers. ConclusionsIschemic events in patients after PAD revascularization were affected by independent risk factors. Decreased clopidogrel metabolism increased the platelet reactivity and CR in patients after PAD revascularization. Furthermore, high platelet reactivity was associated with an increased risk of ischemic events in patients with intermediate and poor metabolism.

Apixaban in patients with atrial fibrillation and acute coronary syndrome in elective percutaneous coronary intervention: what did the subanalysis of the AUGUSTUS trial add to our understanding?

The article is devoted to the results of the subanalysis published after release of the AUGUSTUS trial. The most important conclusion of the parent trial is the evidence that weekly aspirin therapy is sufficient to prevent thrombotic complications in the majority of patients with AF and ACS, as well as those undergoing elective PCI, and that aspirin therapy can be extended up to 1 month after PCI only in a part of patients with additional risk factors for ischemic events and a low risk of bleeding. Four years have passed since the publication of the AUGUSTUS trial results, and all subsequent subanalyses of the trial confirmed its results. The safety and efficacy advantages of apixaban over warfarin were shown to be independent of renal function and consistent with the overall trial results. The advantages of apixaban and the association of aspirin with bleeding were similar in both stroke and non-stroke patients with AF and were dose-independent when a dose was reduced to 2.5 mg twice in accordance with the reduction criteria. The advantages of apixaban over warfarin lasted regardless of time spent in the therapeutic range in the warfarin group. The advantages of apixaban over warfarin and the association of long-term intake of aspirin with bleeding rates persisted in patients with high and low baseline risk of bleeding and stroke. All subanalyses of the AUGUSTUS trial confirmed the efficacy and safety of apixaban, as well as the option to discontinue aspirin at the outpatient stage in the majority of patients with AF, who underwent elective PCI or ACS.

Use of Tirofiban to Prevent Ischemic Events in Patients with CYP2C19 Loss-of-Function Alleles during Flow Diversion of Intracranial Aneurysm: A Multicenter Cohort Study.

To analyze the effect of tirofiban on ischemic events in CYP2C19 loss-of-function (LOF) allele carriers during pipeline embolization device (PED) implantation. Demographic information, imaging data, ischemic complications, CYP2C19 genotyping, and platelet function test results were collected from patients with PED-treated intracranial aneurysms at three centers. Multivariate logistic regression was used to analyze risk factors for ischemic events. Patients were grouped according to LOF alleles and antiplatelet drugs, the baseline information of LOF allele carriers and non-carriers were compared, and the efficacy of tirofiban was analyzed by comparing the incidence of ischemic events in each group. In total, 278 patients were included in the study, 24 of whom had an ischemic event. 157 (56.5%) patients carried the LOF allele and were more likely to develop resistance to clopidogrel (P < 0.001) and hypertension (P = 0.010). Multivariate logistic regression analysis revealed that the independent risk factors for ischemic events were age of > 55years (OR = 3.308, P = 0.028), LOF alleles (OR = 3.960, P = 0.036), and clopidogrel nonresponsiveness (OR = 3.301, P = 0.014). For LOF allele carriers, prophylactic use of tirofiban after PED implantation helped to reduce ischemic events (4.3% vs. 16.4%, P = 0.039). This study supports CYP2C19 genotyping before flow diversion because LOF alleles increase the risk of ischemic events. Prophylactic use of tirofiban may help reduce ischemic events in LOF allele carriers.

Incomplete circle of Willis as a risk factor for intraoperative ischemic events during carotid endarterectomies performed under regional anesthesia - A prospective case-series.

The role of the willisian collaterals during carotid endarterectomies (CEAs) is a debated issue. The aim of the present work was to test whether an incomplete or non-functional circle of Willis (CoW) is a risk factor for ischemic events during CEA. CEAs were performed under local anesthesia. Patients were considered symptomatic (SY) if neurological signs appeared after the cross-clamping phase. In SY patients shunt insertion was performed. CoW on CT angiograms (CTa) were analyzed offline and categorized as non-functional (missing or hypoplastic collaterals) or functional collaterals by three neuroradiologists. Near-infrared spectroscopy (NIRS) was performed throughout the procedure. Based on CTa, 67 incomplete circles were found, 54 were asymptomatic (ASY) and 13 were SY. No complete CoW was found among the SY patients. Significant differences could be detected between incomplete and complete circles between ASY and SY groups (Chi-square: 6.08; p = 0.013). The anterior communicating artery was missing or hypoplastic in 5/13 SY cases. There were no cases of the non-functional anterior communicating arteries in the ASY group (Chi-square: 32.9; p = 10-8). A missing or non-functional bilateral posterior communicating artery was observed in 9/13 SY and in 9/81 ASY patients (Chi-square: 24.4; p = 10-7). NIRS had a sensitivity of 76.9% and a specificity of 74.5% in detecting neurological symptoms. Collateral ability of the CoW may be a risk factor for ischemic events during CEAs. Further studies should delineate whether the preoperative assessment of collateral capacity may be useful in decision-making about shunt use during CEA.

Roles of light transmission aggregometry and CYP2C19 genotype in predicting ischaemic complications during interventional therapy for intracranial aneurysms

Background and purposeLight transmission aggregometry (LTA) and CYP2C19 genotype analysis are commonly used to evaluate the antiplatelet effects of clopidogrel during the interventional treatment of intracranial aneurysms. The aim of...

Intraplaque neovascularisation is associated with ischaemic events after carotid artery stenting: an observational prospective study.

Intraplaque neovascularisation (IPN) is a component of vulnerable atherosclerotic plaque, which is a biomarker of cardiovascular events. However, the identification of patients with high probability of ischaemic events after carotid artery stenting (CAS) is mainly based on vascular risk factors. Prospective studies on the development of plaques are lacking. The purpose of this study was to investigate whether IPN detected by contrast-enhanced ultrasound is related to the occurrence of ischaemic events after CAS. Sixty consecutive patients receiving CAS were prospectively enrolled in our centre. The patients were evaluated using contrast-enhanced ultrasound before CAS. According to the degree of microbubble enhancement, IPN was graded from 0 to 2. Endpoint events, including ischaemic stroke and other cardiovascular events, were recorded during follow-up. Kaplan-Meier survival curves and Cox proportional-hazards models were used to evaluate the risk factors for endpoint events. At a median follow-up of 30 months, 13 patients (28.9%) experienced endpoint events. Kaplan-Meier survival curves showed that patients with grade 2 IPN had a higher risk of future ischaemic events than those with grade 0 or 1 IPN (p < 0.05). Cox proportional-hazards models showed that grade 2 IPN [adjusted hazard ratio (HR), 4.049; 95% confidence interval (CI), 1.078-15.202] was a significant predictor of endpoint events (p < 0.05). Grade 2 IPN evaluated by contrast-enhanced ultrasound has predictive value for ischaemic events in patients after CAS and may help clinicians identify high-risk patients who need close follow-up. Neovascularisation and carotid artery stenting Introduction: Introduction: It is unclear whether intraplaque neovascularisation (IPN) can be used as an biomarker of high probability ischemic events after carotid artery stenting (CAS).Materials and methods: We enrolled 60 patients who underwent CAS, all of whom underwent CEUS before CAS. We recorded ischaemic events during follow-up. Cox proportional-hazards models were used to evaluate the risk factors for ischaemic events.Results: We found that grade 2 IPN was an independent predictor (hazard ratio, 4.049; 95% confidence interval, 1.078-15.202; p < 0.05) of ischaemic events in patients after CAS.Conclusion: This may help clinicians identify high-risk patients who need close follow-up.

Severe Left Atrial Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation: Clinical Characteristics and Impact on Ischemic Risk Postablation.

Spontaneous echo contrast (SEC) is an important precursor for intracardiac thrombus and stroke. There are very limited data on characteristics of severe SEC and its impact on ischemic risk of nonvalvular atrial fibrillation (NVAF) patients after radiofrequency catheter ablation. Transesophageal echocardiography files were reviewed between March 2009 and March 2021 in this monocentric retrospective study. SEC was classified into four levels. The primary endpoint was thromboembolic event (stroke, myocardial infarction, systemic embolism, and ensuing death), and the secondary endpoint included nonischemic mortality and recurrent atrial arrhythmia. Six hundred SEC cases were enrolled and classified into mild SEC group (Grade 1-2, n = 515) and severe SEC group (Grade 3-4, n = 85). Independent risk factors for severe SEC included higher brain natriuretic peptide (BNP), erythrocyte sedimentation rate (ESR), and LAd/∆LVED (LAd = left atrial diameter; ∆LVED = left ventricular end-diastolic diameter - left ventricular end-systolic diameter). The severe SEC group had a higher peri-procedural ischemic event occurrence (7.1 vs. 1.9%, p = 0.007). At a median follow-up of 55 months, the severe SEC group had a lower freedom rate from ischemic events (90.1 vs. 75.3%, p < 0.001); older age and severe SEC were independent risk factors for ischemic events. In patients undergoing redo-procedure (n = 100), a remarkably reduced ESR (17.8 ± 12.0 vs. 28.2 ± 19.0 mm/h, p < 0.001) was observed in patients whose SEC disappeared. Higher BNP, ESR, and LAd/∆LVED were the independent predictors for severe SEC. Severe SEC was associated with higher peri-procedural and long-term ischemic risks. ESR and LAd/∆LVED, as indicators of hematological and hemodynamic change, seemed helpful in identifying NVAF patients prone to developing severe SEC.

Risk factors for ischemic events in residents of Kemerovo and Kemerovo region at 3-year follow-up (results of the urban rural epidemiology study)

The aim of the study was to identify risk factors for ischemic events in residents of Kemerovo and Kemerovo region at 3-year follow-up.Material and methods. The study included participants (n = 638, ages 35 to 70 years), permanently residing in Kemerovo or the Kemerovo region of the prospective epidemiological study conducted at the Research Institute for Complex Issues of Cardiovascular Diseases from 2015 to 2020. The exclusion criteria were prior myocardial infarction (MI), angina pectoris and/or diagnosed peripheral artery disease. The main socio-economic and behavioral characteristic and health status of participants were determined by means of questionnaire, data of some participants were collected from medical records (case history, patient discharge summary, results of laboratory and instrumental examinations). Food Frequency Questionnaire was used to capture an individual`s usual food consumption. International Questionnaire on Physical Activity was used to measure health-related physical activity of participants. Data regarding the end points (all-cause death or death due to cardiovascular events, de novo angina, MI, stroke) were collected at 3-year follow-up.Results. Out of 638 participants, death was reported for 22 cases (of which 4 deaths were due to cardiovascular events), 6 developed non-fatal MI, 45 had de novo angina, and 12 had a non-fatal stroke at 3-year follow-up. A composite endpoint (CE) developed in 80 study participants during 3 years of follow-up. Logistic regression analysis revealed a significant association between CE and the following factors: obesity at the beginning of the study (odds ratio (OR) 2.09, 95 % confidence interval (95 % CI) 1.03–4.26) (an adjusted OR (AOR) 2.17, 95 % CI 1.06–4.44)), regular (at least once a month) alcohol consumption at the time of the survey (OR 2.33, 95 % CI 1.23–4.42 (AOR 2.29, 95 % CI 1.21–4.34)), participants stating that they have been thinking about death during previous month (OR 3.22, 95 % CI 1.54–6.76 (AOR 3.74, 95 % CI 1.73–8.07)). The following factors had the weakest association with the risk of ischemic events at 3-year follow-up: disability due to injury and occupational diseases (OR 0.19, 95 % CI 0.07–0.51 (AOR 0.21 (0.08–0.57)), taking medication for a month (OR 0.37, 95 % CI 0.17–0.81 (AOR 0.36, 95 % CI 0.16–0.80)), in particular, antihypertensive drugs (OR 0.43, 95 % CI 0.22–0.81 (AOR 0.43,95 % CI 0.22–0.82)) and lipid-lowering drugs as a part of primary prevention (OR 0.33, 95 % CI 0.15–0.70 (AOR 0.33, 95 % CI 0.15–0.73)). Moreover, low physical activity associated with the use of transport in daily travels (car, bicycle) proved to be conditionally protective in relation to CE (OR 0.48, 95 % CI 0.25–0.94) (AOR 0.49, 95 % CI 0.25–0.96)).Conclusions. The identification of a number of significant «non-conventional» risk factors for development of ischemic events in residents of Kemerovo and Kemerovo region without prior atherosclerotic cardiovascular diseases at 3-year follow-up allows to consider them as additional modifiable risk factors within the framework of primary prevention.

Abstract WP204: Patients With Traditional Cerebrovascular Risk Factors Are At A Higher Risk Of Stroke After Cervical Artery Dissection

Background: Ischemic stroke is a common complication of cervical artery dissection (CeAD), however, the factors predisposing to stroke are unclear. We aimed to evaluate the timing and risk factors of ischemic events in patients with CeAD. Methods: We identified hospitalizations with carotid artery dissection (CAD) and vertebral artery dissection (VAD) from the Nationwide Readmissions Database 2016-2018. Multivariable logistic regression and Cox regression analyses were used to evaluate the risk factors associated with ischemic events during the index hospitalization and after hospital discharge, respectively. Results: There were 38824 hospitalizations due to CeAD (mean±SD age: 53.7±18.3 years, female: 43.2%); 19769 (50.9%) with acute ischemic stroke (AIS) or transient ischemic attack (TIA) and 19055 (49.1%) without any ischemic events during the initial hospitalization. Advanced age, female sex, both CAD and VAD (in reference to VAD alone), and history of Marfan’s syndrome were associated with lower odds of ischemic events. Whereas history of hypertension, hyperlipidemia, diabetes, tobacco use, obesity, and previous stroke/TIA were associated with higher likelihood of ischemic events at initial presentation. Among 32862 index cases with survival to discharge and known discharge disposition, readmission due to acute ischemic events within 1 year of discharge occurred in 924 (2.8%) patients, with mean±SD time to readmission: 56.6±70.8 days. The risk of readmission due to ischemic events did not differ by the location of CeAD. However, AIS/TIA during the index hospitalization [hazards ratio (HR): 3.1, 95% confidence interval (CI): 2.5-4.0), history of hyperlipidemia (HR: 1.3, 95% CI: 1.1-1.6), diabetes (HR: 1.5, 95% CI: 1.2-1.8), tobacco use (HR: 1.3, 95% CI: 1.1-1.6), and head/neck vessel atherosclerosis (HR: 1.3, 95% CI: 1.1-1.6) were independently associated with a higher risk of delayed ischemic events. Conclusion: Nearly half of the hospitalized patients with CeAD have ischemic events at initial presentation. Delayed ischemic events are possible, however, occur in a relatively small proportion of patients. Comorbid cerebrovascular risk factors are associated with both concurrent and delayed ischemic events in patients with CeAD.

High On-Treatment Platelet Reactivity as Predictor of Long-term Clinical Outcomes in Stroke Patients with Antiplatelet Agents.

The purpose was to explore the value of high on-treatment platelet reactivity (HTPR) in predicting long-term clinical outcomes for stroke patients. The platelet reactivity was assayed after being treated with either 75mg clopidogrel or 100mg aspirin daily with VerifyNow System in stroke patients. HTPR for clopidogrel was defined as PRU ≥ 208, and that for aspirin was defined as ARU ≥ 550. CYP2C19 genotyping was performed using the Sequenom MassARRAY iPLEX platform. The primary endpoint was a composite of recurrent ischemic stroke, transient ischemic attack, myocardial infarction, or ischemic vascular death. The safety endpoint was bleeding. In the clopidogrel group, among 345 patients recruited, 174 of them were categorized as HTPR. A total of 270 patients were followed up for 54months. There was a significant association between HTPR and the primary endpoint (HRadj 2.13 [95% CI, 1.43-3.15], p < 0.001). Among the 314 participants genotyped for CYP2C19, 187 (59.6%) were classified as CYP2C19 loss-of-function allele carriers. Patients with at least 1 loss-of-function allele were more likely to present with HTPR (ORadj 2.61 [95%CI, 1.43-4.77], p = 0.008), and had a higher risk of the primary endpoint (HRadj 2.05 [95% CI, 1.30, 3.25], p = 0.002). In the aspirin group, among 140 patients recruited, 28 of them were categorized as HTPR. A total of 121 patients were followed up for 30months. Similarly, there was a significant association between HTPR and the primary endpoint (HRadj 3.28 [95% CI, 1.52-7.71], p = 0.002). HTPR is an independent risk factor for ischemic events during long-term follow-up in stroke patients. Platelet function testing is helpful to evaluate the effect of antiplatelet therapy for stroke patients.

Peripheral Artery Disease in Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy; Results From the MR CLEAN Registry

Background and Purpose: Though peripheral artery disease (PAD) is a well-known risk factor for ischemic events, better outcomes have been described in acute ischemic stroke patients with co-existing PAD. This paradoxical association has been attributed to remote ischemic preconditioning (RIPC) and might be related to better collateral blood flow. The aim of this study is to compare outcomes after endovascular thrombectomy (EVT) in acute stroke patients with and without PAD and to assess the relation between PAD and collateral grades.Methods: We analyzed acute ischemic stroke patients treated with EVT for an anterior circulation large artery occlusion, included in the Dutch, prospective, multicenter MR CLEAN Registry between March 2014 and November 2017. Collaterals were scored on CT angiography, using a 4-point collateral score. We used logistic regression analysis to estimate the association of PAD with collateral grades and functional outcome, assessed with the modified Rankin Scale (mRS) at 90 days. Safety outcomes included mortality at 90 days, symptomatic intracranial hemorrhage, and stroke progression.Results: We included 2,765 patients for analysis, of whom 254 (9.2%) had PAD. After adjustment for potential confounders, multivariable regression analysis showed no association of PAD with functional outcome [mRS cOR 0.90 (95% CI, 0.7–1.2)], collateral grades (cOR 0.85, 95% CI 0.7–1.1), or safety outcomes.Conclusion: In the absence of an association between the presence of PAD and collateral scores or outcomes after EVT, it may be questioned whether PAD leads to RIPC in patients with acute ischemic stroke due to large vessel occlusion.

Impact of Routine Platelet Reactivity Testing with VerifyNow Assay on Antiplatelet Choice After Percutaneous Coronary Intervention.

BackgroundHigh on-treatment ADP platelet reactivity (HPR) measured by VerifyNow P2Y12 assay (VN) is an established risk factor for ischemic events after percutaneous coronary intervention (PCI). We hypothesized that routine use of VN at time of PCI in clinical practice may affect choice of P2Y12 antiplatelet therapy at discharge.MethodsIn a single center retrospective analysis, we examined the influence of VN testing on choice of P2Y12 inhibitor post PCI in routine clinical practice. Assessment of HPR was used routinely in clinical care during the time period of analysis at discretion of clinical providers. Subjects with PRU>208 after the loading dose of clopidogrel or during clopidogrel steady state were switched to alternate P2Y12 inhibitors.ResultsWe identified 1001 patients with PCI during the time period specified. A total of 252 subjects underwent VN testing. Among those, 43% were found to have HPR on clopidogrel and were switched to alternate therapies (prasugrel [n=60], ticagrelor [n=48]). Patients who had VN platelet function testing were more likely to be discharged on clopidogrel as compared to those who did not have VN assay done (57% vs. 50%, p=0.039). There was no significant difference in 1-year net-MACE (CVD, MI, stent thrombosis, BARC 2 or higher bleeding) using tailored antiplatelet therapy (VN testing) as compared to standard of care group (adjusted HR:0.92, 95% CI: 0.54–1.5, p=0.74).ConclusionRoutine use of VN assay in personalized antiplatelet treatment decision-making after PCI is associated with lower likelihood of using novel P2Y12 inhibitors.

Expansive carotid artery remodeling: possible marker of vulnerable plaque.

Accumulated findings in the pathophysiology of atherosclerosis have demonstrated that not only luminal narrowing but also plaque characteristics influence the risk of future ischemic events. The morphology of the carotid artery (CA) changes in response to atherosclerotic development by expansive remodeling (ER), the clinical significance of which remains unclear. This study aimed to define associations between ER and local risk factors, including CA geometry and traditional systemic risk factors for ischemic events, to determine whether ER could serve as a clinical marker of carotid vulnerable plaque. The authors retrospectively analyzed 66 patients with CA stenosis who were scheduled to undergo carotid endarterectomy or CA stenting. They calculated ER ratios in the internal CA (ICA) from long-axis MR images and as the maximal distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA/the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis. Relative overall signal intensity (roSI) was calculated to assess intraplaque hemorrhage and defined as the signal intensity of plaque on an axial T1-weighted image with maximal stenosis relative to that of the adjacent sternocleidomastoid muscle. The authors evaluated CA geometry by calculating the angles between the common CA (CCA) and ICA, and between the CCA and external CA (ECA) using digital subtraction angiography. The ER ratios, age, sex, percentage of stenosis, roSI, hypertension, hyperlipidemia, low-density lipoprotein, statin medication, diabetes, smoking habit, and ischemic heart disease were compared between 33 symptomatic and 33 asymptomatic patients. The authors also compared symptomatic status, age, sex, percentage of stenosis, ICA angle, ECA angle, roSI, and other traditional atherosclerotic risk factors between groups with extensive and slight ER. The ER ratio was significantly greater in symptomatic than in asymptomatic patients (1.91 ± 0.46 vs 1.68 ± 0.40, p < 0.05). The ICA angle was significantly larger in the group with extensive ER than in those with slight ER (33.9° ± 20.2° vs 21.7° ± 13.8°, p < 0.01). The roSI, ECA angle, percentage stenosis, or any other traditional vascular risk factors were not associated with ER. Carotid ER might be an independent indicator of carotid vulnerable plaque, which should be validated in a longitudinal study of patients with carotid atherosclerosis, including those with nonstenotic to moderate stenosis.

Mean Corpuscular Volume Predicts In-Stent Restenosis Risk for Stable Coronary Artery Disease Patients Receiving Elective Percutaneous Coronary Intervention.

BackgroundThe purpose of this study was to analyze predictive performance of MCV in midterm ischemic events among SCAD patients undergoing elective PCI.Material/MethodsWe retrospectively included 226 consecutive patients with SCAD who received elective PCI. The patients were grouped based on MCV quartile values. The prognostic significance of MCV was assessed using univariate and multivariate Cox proportional hazard regression analyses.ResultsAccording to MCV quartile points (87.5 fL, 89.7 fL, and 92.4 fL, respectively), the included patients were divided into 4 groups, with an average follow-up of 34.2 months. There were 28 (48.3%) patients with stent thrombosis in the 1st quartile, 24 (29.1%) in the 2nd quartile, 18 (31.6%) in the 3rd quartile, and 15 (27.8%) in the 4th quartile (log-rank test, P=0.027). Multivariate analysis confirmed that MCV 1st quartile (HRadj=2.047, 95% CI 1.041–4.026; P=0.038), ALT (HRadj=1.013, 95% CI 1.004–1.023; P=0.004) and number of PCI vessels (HRadj=1.198 95% CI 1.013–1.415; P=0.034) were risk factors for ischemic events. The restenosis rate in patients belonging to the MCV 1st quartile was 2 times higher than that in MCV 2nd, 3rd, and 4th quartile groups (P=0.007).ConclusionsMCV value may be independently correlated with restenosis in SCAD patients undergoing PCI. Low MCV predicts high risk of in-stent restenosis.

Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants - A systematic review.

BackgroundNon-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce.ObjectiveSystematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis.Data sourcesPubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018.Study eligibility criteria52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients.Study appraisal and synthesis methodWe systematically assessed study quality using a bias tool and pooled consistent data.ResultsExisting data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging.LimitationsLimited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings.ConclusionsAcute ischemic events despite treatment with NOAC therapy are insufficiently investigated.Systematic review registration numberPROSPERO: CRD42018074853.

Benefits and Risks of Anticoagulation in Acute Coronary Syndrome.

Both antiplatelets and anticoagulants are necessary in the management of acute coronary syndrome (ACS), although the exact proportion of antithrombotic effect that each drug and class should ideally provide remains a matter of ongoing study. Defining the best combination between the antiplatelet agents and oral anticoagulants (OACs) can be challenging. The choice is particularly important for special categories of patients with ACS who have an indication of a long-term OAC. A literature search regarding benefits and risks of anticoagulation in ACS was conducted through MEDLINE and EMBASE (past 20 years until September 2018). Many patients with ACS have an indication for long-term OACs. Those receiving dual antiplatelet therapy and anticoagulants are considered to be at a high bleeding risk. The addition of a vitamin K antagonist (VKA) imposes a target international normalized ratio of 2.0-3.0. When non-VKA oral anticoagulants are used, the lowest effective tested dose for stroke prevention should be applied. For most patients, triple therapy in the form of an OAC plus dual antiplatelet therapy [aspirin and P2Y12 inhibitors (usually clopidogrel)] should be considered for 3-6 months. Later, dual therapy (OAC plus aspirin or clopidogrel) should be considered for an additional 6 months. After 1 year, it is recommended that only the OAC is maintained. In cases of very high bleeding risk, triple therapy can be reduced to 1 month after ACS, continuing on dual therapy up to 1 year, and thereafter only anticoagulation. In general, the bleeding risk seems to be lower with non-VKA oral anticoagulants than VKA plus antiplatelet combination. Many risk factors for ischemic events and bleeding overlap. The clinician's challenges include monitoring patients' adherence and global assessment of the antithrombotic effect that incorporates antiplatelet and anticoagulant effects.

A study of correlation between Platelet Volume Indices (PVI) in patients of Dyslipidemia in tertiary care hospital

Background:The dyslipidemia is a risk factors for cardiovascular disease. Ischemic heart disease istheleadingcauseofdeath worldwide. Platelet volume reflects platelet reactivity and has been suggested as an independent risk factor for ischemic events in cardiovascular disease. We have shown preliminary results on production of larger platelets by Mean Platelets Volume (MPV) and Platelets Distribution Width (PDW) determination in a group of patients with lipid profile abnormalities. Materials &Method:The study was performed in patients coming to GMERS Medical College, Junagadh from June 2016 to December 2017. Bloodsamplewascollectedinplaintubefor lipidprofileanalysis,EDTA vaccutainer for haematological analysis. PVI were obtained by usingHorriba 5 part automatedcellcounter & Lipid profile parameters by fully automated analyzer Roche’s COBAS INTEGRA 400plus. Results:our study comprising of 500 patient’s samples and 50 control samples, In patient’s group high levels of total cholesterol correlates more with high value of PDW than with MPV. Conclusion:PVI like MPV and PDW are strongly associated with dyslipidemia. The estimation of these PVI can be considered as an early, economicalandrapidprocedurefor identificationofcomplicationsinhyperlipidemic patients.