Risk Of Cerebrovascular Events Research Articles

Cost-effectiveness of atrial fibrillation detection with insertable cardiac monitors in large-artery or small-vessel disease stroke in the United Kingdom

Abstract Background The randomised STROKE-AF trial demonstrated clinical effectiveness of continuous cardiac monitoring to detect atrial fibrillation (AF) with insertable cardiac monitors (ICMs) for patients with ischemic stroke attributed to large-artery or small-vessel disease (LAD/SVD). ICMs were ten-fold more effective at detecting AF compared to the standard of care (SoC). However, cost-effectiveness of this monitoring strategy is unknown. Purpose The aim of this economic evaluation was to assess the cost-effectiveness of long-term continuous cardiac monitoring via ICMs, for detection of AF (and, in event of AF diagnosis, subsequent anticoagulation), in patients with ischemic stroke attributed to large-or-small vessel disease compared to the SoC of conventional follow up in the United Kingdom. Methods We constructed a Markov model with a cycle length of three months and a lifetime horizon to conduct the cost-effectiveness analysis, from the National Health Service (NHS) perspective. Costs and health-related benefits were discounted at an annual rate of 3.5%. We expressed outcomes in terms of quality-adjusted life-years (QALYs). Patient characteristics in the analysis and detection probabilities were based on the STROKE-AF trial. Detection of AF resulted in a switch in treatment from antiplatelet to direct oral anticoagulant (DOAC). Risk of cerebrovascular events were dependent on a patient’s AF detection status and subsequent treatment. Scenario, deterministic, and probabilistic sensitivity analyses were conducted to test the robustness of the base-case incremental cost-effectiveness ratio (ICER) and account for uncertainties in the model. We stratified patients into risk groups based on CHA2DS2-VASc scores and risk of AF detection. Results The base case incremental cost-effectiveness ratio of the implantation of an ICM was £15,485 per QALY, substantially under the NICE willingness-to-pay threshold of £20,000-£30,000 per QALY. ICM implantations resulted in 0.139 QALYs gained per patient at an incremental cost of £2,147. There were 0.054 fewer stroke events per patient in the ICM arm versus SoC. Results were robust under sensitivity analysis. Conclusion ICMs were cost-effective compared to SoC for detection of AF in patients with LAD/SVD stroke in the United Kingdom driven largely by more stroke events avoided. Subgroup analysis showed that ICMs were more cost-effective in patients with higher CHA2DS2-VASc scores and those with a higher individual risk of AF.Markov Model SchematicSummary ICER Results and Events avoided

#850 The association between proteinuria and stroke: results from the non-communicable diseases screening programme of Chiang Mai Region, Northern Thailand

Abstract Background and Aims Stroke is a significant global health issue, representing the second leading cause of death and a major contributor to disability. It can be classified into two main types: ischemic stroke, caused by blockage of a brain blood vessel, and haemorrhagic stroke, resulting from blood vessel rupture. Chronic kidney disease (CKD) is another prevalent health concern, affecting approximately 10% of all populations worldwide. CKD impairs kidney function and has been associated with an increased risk of cerebrovascular events, including stroke. Within the Northern Thai population, the prevalence of CKD is higher than the global average, underscoring the importance of investigating the relationship between CKD and stroke in this region. Method All patients for which accurate proteinuria measurement was obtained as part of the NCD screening program in Chiang Mai, Northern Thailand were included in the study. Multilinear cox regression analysis was used to estimate the hazards ratio for the association between proteinuria on stroke. The model was adjusted for other significant confounders of the association including age, sex, CKD, diabetes, hypertension and hypercholesterolaemia Results In a cohort of 3967 patients for which accurate proteinuria measurements were obtained and for whom had complete data for covariates, there was no evidence for an association between proteinuria and stroke. Hazards ratio for stroke in patients with trace proteinuria (adjusted for covariates) was 1.08 (95% CI 0.80-1.45) and positive proteinuria 0.06 (0.78-1.44) compared to a baseline of no proteinuria. Conclusion This study provides important insights into stroke risk factors in the Northern Thai population. The lack of substantial association between proteinuria and stroke suggests that proteinuria may not independently contribute to stroke risk in this cohort. Generalizability, however, is limited due to overrepresentation of diabetes and hypercholesterolaemia in the cohort, which is a strong independent risk factor for stroke. Increasing age is identified as the most critical risk factor for stroke. Understanding these associations can guide targeted interventions and public health strategies for stroke prevention in this population. The study limitations highlight the importance of analysis of a cohort that is more representative of a wider population in terms of chronic disease, such as diabetes and hypercholesterolaemia, and highlights the importance of longer follow up to fully elucidate whether proteinuria has an association with stroke. Furthermore the study raises questions as to whether measurement of proteinuria via urine dipstick analysis may limit conclusions that can be drawn compared to more robust methods such as urine albumin:creatinine or urine protein:creatinine ratios. Finally this study may be underpowered to detect subtle changes of a hazards ratio of less than 1.2, so is at risk of a type 2 statistical error.

Comparing clinical profiles, in-hospital complications and one-year cerebrovascular events in typical and midventricular TTS-results from a retrospective study between two third-level centers

Abstract Funding Acknowledgements None. Background Apical ballooning is considered the typical form of Takotsubo syndrome (TTS) and occurs in about 75-80% of cases. Midventricular (MV) is the most frequent atypical variant and represents about 15% of TTS. Clinical and analytical characteristics, early complications and the risk of cerebrovascular events (CVEs) between these two specific groups are poorly studied. Purpose of the study To investigate the clinical profile, laboratory variables, in-hospital complications and one-year CVEs between typical and MV variants of TTS. Methods we retrospectively examined the patients admitted to two third-level hospitals with a diagnosis of TTS. A total of 248 TTS met InterTAK diagnostic criteria. Clinical features, myocardial enzymes, echocardiographic variables, early complications and one-year CVEs were assessed. Results Of 248 patients diagnosed with TTS, a total of 205 (83%) patients presented with typical and 43 (17%) with MV variant of TTS. Patients with MV form were younger (age mean ± SD 68 ± 12 vs 74 ± 11 years, p value = 0.002) and had a lower incidence of hypertension (46% vs 73%; p value < 0.001) than those with apical variant. On admission, patients with MV form presented a lower degree of left ventricular dysfunction (EF mean ± SD, 44 ± 9% vs 41 ± 9%, p value = 0.018) and a tendence not to present left ventricular outflow tract obstruction (LVOTO) (0 vs 9%, p value = 0.049). Lower N-terminal pro-brain natriuretic peptide (NT-proBNP) levels on admission (median [IQR], 881 [99 – 3049] pg/mL vs 3466 [677 - 9067] pg/mL, p value <0.001) and at peak (3150 [947- 4437] pg/mL vs 4622 [1886 - 13163] pg/mL, p value = 0.005) were observed in MV group compared to the typical form. In-hospital cardiovascular (CV) complications were frequently observed (46% in the overall population) and appeared to be more frequent in the typical variant (51% vs 33%, p value= 0.035); in particular, we reported a higher prevalence of AF (16% vs 2%, p value = 0.022). The number of CS and VT cases is remarkable in both the subgroups (13% vs 7%; 5% vs 2%), with a higher prevalence in the typical form, even if not reaching a statistically significant difference between the two groups (p= 0.437; p= 0.695). No significant differences were observed in LV thrombosis, and in on admission and one-year CVEs between the two groups, although with a higher prevalence in the typical variant (respectively 3 vs 0, 10 vs 1 and 5 vs 0). Conclusions MV TTS presents some differences in clinical characteristics, analytical values and echocardiographic parameters compared to the typical variant. In-hospital CV complications are remarkable, and more frequently observed in typical variant, although not reaching a statistically significant difference in CS and VT. Similarly, more CVE were observed in the typical TTS group, although in the absence of a statistical significance. The importance of close monitoring in the acute phase is confirmed for both variants under study.

Aldosterone is Associated With New-onset Cerebrovascular Events in Patients With Hypertension and White Matter Lesions: A Cohort Study

ObjectiveWhite matter lesions (WMLs) increase the risk of stroke, stroke recurrence, and death. Higher plasma aldosterone concentration (PAC) increases the risk of stroke, acute myocardial infarction, and hypertension. The objective is to evaluate the relationship between PAC and cerebrovascular events in patients with hypertension and WMLs. MethodsWe conducted a retrospective cohort study that included 1041 participants hospitalized. The outcome was new-onset cerebrovascular events including intracerebral hemorrhage and stroke. A Cox regression model was used to evaluate the relationship between baseline PAC and the risk of cerebrovascular events. ResultsThe mean age of participants was 60.9 ± 10.2 years and 565 (53.4%) were males. The median follow-up duration was 42 months (interquartile range: 25-67), and 92 patients experienced new-onset cerebrovascular events. In a multivariate-adjusted model, with PAC as a continuous variable, higher PAC increased the risk of cerebrovascular events; patient risk increased per 1 (hazard ratio [HR: 1.03], 95% confidence interval [CI]: 1.01-1.06, P < .01), per 5 (HR: 1.17, 95% CI: 1.06-1.31, P < .01), and per 10 ng/dL (HR: 1.41, 95%: 1.14-1.75, P < .01) increase in PAC. When PAC was expressed as a categorical variable (quartile: Q1-Q4), patients in Q4 (HR: 2.12, 95% CI: 1.18-3.79, P < .05) exhibited an increased risk of cerebrovascular events compared to Q1. Restrictive spline regression showed a linear association between PAC and the risk of new-onset cerebrovascular events after adjusting for all possible variables. ConclusionsOur study identified a linear association between PAC and the risk of new-onset cerebrovascular events in patients with hypertension and WMLs.

Molecular Pathways of Vulnerable Carotid Plaques at Risk of Ischemic Stroke: A Narrative Review.

The concept of vulnerable carotid plaques is pivotal in understanding the pathophysiology of ischemic stroke secondary to large-artery atherosclerosis. In macroscopic evaluation, vulnerable plaques are characterized by one or more of the following features: microcalcification; neovascularization; lipid-rich necrotic cores (LRNCs); intraplaque hemorrhage (IPH); thin fibrous caps; plaque surface ulceration; huge dimensions, suggesting stenosis; and plaque rupture. Recognizing these macroscopic characteristics is crucial for estimating the risk of cerebrovascular events, also in the case of non-significant (less than 50%) stenosis. Inflammatory biomarkers, such as cytokines and adhesion molecules, lipid-related markers like oxidized low-density lipoprotein (LDL), and proteolytic enzymes capable of degrading extracellular matrix components are among the key molecules that are scrutinized for their associative roles in plaque instability. Through their quantification and evaluation, these biomarkers reveal intricate molecular cross-talk governing plaque inflammation, rupture potential, and thrombogenicity. The current evidence demonstrates that plaque vulnerability phenotypes are multiple and heterogeneous and are associated with many highly complex molecular pathways that determine the activation of an immune-mediated cascade that culminates in thromboinflammation. This narrative review provides a comprehensive analysis of the current knowledge on molecular biomarkers expressed by symptomatic carotid plaques. It explores the association of these biomarkers with the structural and compositional attributes that characterize vulnerable plaques.

Association Between a Brain Care Score and Risk of Cerebrovascular Events in American Women (S11.004)

Association Between a Brain Care Score and Risk of Cerebrovascular Events in American Women (S11.004)

Abstract P243: Association Between a Brain Care Score and Risk of Cerebrovascular Events in American Women

Background: The McCance Brain Care Score (MBCS) is a novel tool derived through a modified Delphi process to motivate lifestyle changes to reduce the risk of cerebrovascular events (CVE) based on prior studies and expert knowledge. However, few studies to date have determined the association between the MBCS and incident CVE. Studying this potential association is particularly important given the higher risk of stroke among women and the potential for unique risk profiles given physiologic and pharmacologic hormonal changes across the lifespan. Methods: The study population was participants in the Women’s Health study (WHS) who had available risk factor information needed to calculate the modified MBCS 5 years after enrollment and no prior history of CVE. The WHS-adaptation of the MBCS is illustrated in Figure 1; higher scores suggest better brain health. Participants were followed from MBCS assessment until first CVE (Stroke or Transient Ischemic Attack), end of study, loss to follow-up, or death, whichever occurred first. CVE were confirmed by medical record review. Cox proportional hazards models were used to examine the association between the MBCS, modeled as a continuous variable, and incident CVE adjusted for potential confounders. Results: In total, 22,965 women were eligible with a median age of 58.0 (Interquartile Range 54.0-63.9) and median MBCS of 15 (14-17). There were 1,364 (5.9%) incident CVE events during a median follow-up of 22.5 (16.8-23.6) years. A one-point higher baseline MBCS was associated with 11% decreased risk of incident CVE after adjusting for age, postmenopausal status, and use of hormonal replacement therapy (HR=0.89; 95%CI=0.87-0.91). This association remained significant after adjusting for comorbidities, race, educational attainment, and income (HR=0.90; 95%CI=0.88-0.93). Conclusion: Higher baseline MBCS was associated with a decreased risk of incident CVE among women. Future studies are needed to understand how longitudinal changes in the MBCS impact risk of CVE.

Epidemiology and management of transient ischemic attack in Trieste district, how day hospital assessment improves outcomes: a five-year retrospective study.

Transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction, without acute infarction or tissue injury lasting less than 24h. Previous data suggest TIA precedes 15% of ischemic strokes, with a higher risk in the first week. Current practice guidelines advise evaluation through rapid neurological visit or admission to hospital. We provide data on TIA incidence in Trieste, and we compare three different types of assessment: day hospital (DH), stroke unit (SU), and emergency department/outpatients (ED). This is a 5-year retrospective study of transient cerebrovascular events admitted in the University Hospital of Trieste (230.623 inhabitants), between 2016 and 2020. We calculated TIA prevalence in Trieste district's general population. Our primary endpoint is ischemic recurrences within 90days, and we evaluate the possible association between different types of management. TIA incidence rate was 0.54/1000 inhabitants. In the multivariate analysis remained significantly associated with primary endpoint: ABCD2 (OR 1.625, CI 95% 1.114-2.369, p = 0.012) and DH evaluation (OR 0.260, CI 95% 0.082-0.819, p = 0.021). Incidence of TIA in Trieste district is in line with previous data. We demonstrate the crucial role of DH evaluation over the outpatient/ED in reducing overall mortality and recurrence rate. Prompt recognition of patients at high risk for cerebrovascular events and specialist follow-up may reduce the incidence of major vascular events and death.

Abstract 110: Pre-Operative Risks of Major Adverse Cerebrovascular Events in Pediatric Moyamoya Disease

Objective: This study aims to evaluate the risk of cerebrovascular events in pediatric MMD during the preoperative waiting period, and explore the related risk factors and appropriate operation opportunities. Methods: This study is an observational cohort study, including 736 children with MMD from their initial visit until the completion of surgery. The patients were divided into three subgroups according to their initial symptoms: no cerebrovascular event group, cerebral infarction (CI) group, and transient ischemic attack (TIA) group. Results: A total of 736 children with MMD were included, and the median time from diagnosis to surgery was 13 months (IQR: 4-33). During the waiting period, 166 patients (26.6%) experienced CI, and 17 patients (2.3%) had cerebral hemorrhage. The incidence rates of CI and cerebral hemorrhage were 10.49 and 1.08 per 1000 person-months, respectively. Cox regression analysis revealed that male (HR: 1.586; p=0.004), CI at onset (HR: 2.889; p&lt;0.001) or TIA at onset (HR: 1.943; p=0.006), age≤3 years at onset (HR: 2.208; p&lt;0.001), and involvement of the posterior cerebral arteries (HR: 1.670; p=0.001) were risk factors for CI during the waiting period. No specific risk factors for cerebral hemorrhage during the waiting period were identified. For patients with CI at onset, the risk of CI during the waiting period significantly increased when the waiting time exceeded 2.5 months (AUC=0.722, specificity=0.561, sensitivity=0.882; OR: 8.253; p&lt;0.001). In pediatric MMD patients without cerebrovascular events at onset, the risk of preoperative cerebral hemorrhage significantly increased when the waiting time exceeded 5 years (AUC=0.761, specificity=0.856, sensitivity=0.571; OR: 6.667; p=0.018). No significant correlation was found between waiting time and preoperative CI in TIA patients. Conclusions: For children MMD with CI or TIA at onset, early surgery is recommended, especially for younger patients and those with involvement of the posterior circulation. For patients with CI at onset, surgery should be performed within 2.5 months of waiting, while patients without cerebrovascular events should undergo surgery within 5 years.

Factors Affecting Late Atrial Fibrillation and Its Association With Coronary Artery Bypass Outcomes

BackgroundAlthough predictors and outcomes of postoperative atrial fibrillation (POAF) are well studied, evidence is lacking concerning postdischarge late/recurrent atrial fibrillation (AF). This study evaluated factors affecting late/recurrent AF and its association with coronary artery bypass grafting (CABG) outcomes in a real-world setting. MethodsFrom 2012 through 2016, 5175 patients were included. Independent factors associated with late/recurrent AF were identified in a competing risk setting. Cox proportional hazard regression was used to evaluate the association between late/recurrent AF and study outcomes, consisting of all-cause mortality, major adverse cardio-cerebrovascular events, acute coronary syndrome, cerebrovascular events, and heart failure admissions. ResultsDuring a median follow-up of 60 months (quartile 1-quartile 3, 59.3-60.7 months), late/recurrent AF developed in 85 patients (1.64%). Independent factors associated with late/recurrent AF were age (subdistribution hazard ratio [sHR], 1.04; 95% CI, 1.02-1.07), left-ventricular ejection fraction (sHR, 0.97; 95% CI, 0.95-0.99), length of stay (sHR, 1.02; 95% CI, 1.01-1.04), and POAF (sHR, 4.02; 95% CI, 2.50-6.45). Late/recurrent AF was not significantly associated with all-cause mortality and major adverse cardio-cerebrovascular events at unadjusted or adjusted levels (adjusted hazard ratio, 0.80 [95% CI, 0.50-1.28] and 0.74 [95% CI, 0.48-1.13], respectively). Nevertheless, it significantly increased the unadjusted risk of cerebrovascular events (hazard ratio, 2.28; 95% CI, 01.07-4.87), which disappeared after adjustments. ConclusionsPatients with advanced age, a lower left-ventricular ejection fraction, and POAF are more likely to have late/recurrent clinical AF. Albeit counterintuitive, late/recurrent AF was not independently associated with worse midterm post-CABG outcomes. These observations need to be further elucidated in larger-scale studies and interpreted in the context of a developing country with limited resources for late AF surveillance.

Abstract TP231: Incidence of Stroke and Transient Ischemic Attack in Adults With Congenital Heart Disease: A Systematic Review and Meta-Analysis

Introduction: Congenital cardiac lesions result in abnormal flow patterns that increase risk of cerebrovascular events. We investigated the incidence of stroke and transient ischemic attack (TIA) in adults with congenital heart disease (ACHD). Methods: A systematic review was performed per PRISMA guidelines to identify all studies reporting the incidence of stroke and TIA in ACHD. Two independent reviewers screened studies, which were included if patients were age 16 and older with congenital heart disease, and if the outcome was stroke or TIA. Random-effects meta-analysis was conducted to estimate the pooled incidence rate of stroke and TIA with 95% confidence intervals. The Newcastle-Ottawa Scale for risk of bias was applied. This systematic review is registered (CRD42022322144). Results: Of 11,028 identified abstracts, 27 studies met inclusion criteria. 22 studies reported mean or median age, which was less than 60 years in 18 studies. 39 estimates of incidence rates from 24 studies were entered in the meta-analysis. The pooled incidence rate estimate of stroke and TIA was 0.58 per 100 person years, with significant heterogeneity between studies (95% CI 0.39-0.86, I2 97.8%, p&lt;0.001). Secondary analyses were performed stratified by CHD and outcome subtype. The pooled incidence rate of ischemic stroke was estimated at 0.59 per 100 person years (95% CI 0.36-0.95, I2 98%, p=0.01). Conclusions: This meta-analysis found that the incidence rate of stroke and TIA is higher in ACHD than age-adjusted global estimates, and similar to the American Heart Association reported global ischemic stroke incidence rate for individuals &gt;60 years (0.52 per 100 person years).

Prospective evaluation of upper extremity access and total transfemoral approach during fenestrated and branched endovascular repair

ObjectiveTotal transfemoral (TF) access has been increasingly used during fenestrated-branched endovascular aortic repair (FB-EVAR). However, it is unclear whether the potential decrease in the risk of cerebrovascular events is offset by increased procedural difficulties and other complications. The aim of this study was to compare outcomes of FB-EVAR using a TF vs upper extremity (UE) approach for target artery incorporation. MethodsWe analyzed the clinical data of consecutive patients enrolled in a prospective, nonrandomized clinical trial in two centers to investigate the use of FB-EVAR for treatment of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA) between 2013 and 2022. Patients were classified into TF or UE access group with a subset analysis of patients treated using designs with directional branches. End points were technical success, procedural metrics, 30-day cerebrovascular events defined as stroke or transient ischemic attack, and any major adverse events (MAEs). ResultsThere were 541 patients (70% males; mean age, 74 ± 8 years) treated by FB-EVAR with 2107 renal-mesenteric TAs incorporated. TF was used in175 patients (32%) and UE in 366 patients (68%) including 146 (83%) TF and 314 (86%) UE access patients who had four or more TAs incorporated. The use of a TF approach increased from 8% between 2013 and 2017 to 31% between 2018 and 2020 and 96% between 2021 and 2022. Compared with UE access patients, TF access patients were more likely to have CAAAs (37% vs 24%; P = .002) as opposed to TAAAs. Technical success rate was 96% in both groups (P = .96). The use of the TF approach was associated with reduced fluoroscopy time and procedural time (each P < .05). The 30-day mortality rate was 0.6% for TF and 1.4% for UE (P = .67). There was no early cerebrovascular event in the TF group, but the incidence was 2.7% for UE patients (P = .035). The incidence of MAEs was also lower in the TF group (9% vs 18%; P = .006). Among 237 patients treated using devices with directional branches, there were no significant differences in outcomes except for a reduced procedural time for TF compared with UE access patients (P < .001). ConclusionsTF access was associated with a decreased incidence of early cerebrovascular events and MAEs compared with UE access for target artery incorporation. Procedural time was decreased in TF access patients irrespective of the type of stent graft design.

Real-world effectiveness and safety of evolocumab in very high-risk atherosclerotic cardiovascular disease patients with acute ischemic stroke.

We investigated evolocumab's real-world effectiveness and safety on a background of statin therapy in the acute phase of ischemic stroke (IS) patients with a very high-risk of atherosclerotic cardiovascular disease (ASCVD). A real-world, single-center, retrospective study was conducted in the neurology department at Tianjin Huanhu Hospital in China. Patients were divided into two groups: evolocumab treatment (140mg every two weeks) or the standard of care (SOC) group. The primary efficacy outcome of the study was the achievement of a targeted lipid control rate and the incidence of major adverse cardiovascular events (MACE) by the end of the follow-up. MACE was defined as a composite of various cardiovascular events, cerebrovascular events such as stroke or TIA, and event-related deaths. Propensity score matching (PSM) analysis was utilized to account for confounding factors between groups. Survival analyses were performed using the Kaplan-Meier method and COX regression modeling. 1080 AIS patients with very high-risk ASCVD were recruited. After PSM, there were 528 individuals, with 206 in the evolocumab group and 322 in the SOC group. At 12 months of follow-up, the proportion of LDL-C < 1.4mmol/L and ≥ 50% reduction was 44.91% in the evolocumab group, compared with only 3.12% of SOC-treated patients (p < 0.01). The median follow-up time for clinical events was 15 months. The evolocumab group was associated with a lower risk of cerebrovascular events compared to the SOC group (HR, 0.45; 95% CI, 0.23-0.89; p = 0.02). This real-world study suggested that evolocumab on a background of statin reduced the LDL-C levels significantly and lowered the incidence of recurrent cerebrovascular events in the very high-risk ASCVD patients with AIS in China.

Microemboli on Transcranial Doppler in Patients with Sickle Cell Disease: A Single Center Case Series

Background: Stroke remains a major cause of morbidity in patients with sickle cell disease (SCD). Current guidelines recommend that patients with Hemoglobin SS and Hemoglobin S beta zero thalassemia have annual transcranial doppler (TCD) screening and that patients with abnormal velocities should have regular blood transfusions to maintain a maximum HbS level &amp;lt;30% and maintain a hemoglobin level &amp;gt;9 g/dL for at least one year to decrease risk of stroke (DeBaun et al., 2020). While research has shown that patients with velocities &amp;gt;200cm/sec are at increased risk of cerebral infarct, there is no literature to discuss the follow up and management of patients with microemboli on TCD. In the past microemoli were unable to be detected, however TCD is now able to detect such findings (Wan et al., 2022). Studies have been completed on patients with ischemic stroke without SCD and have shown that the presence of microemboli on TCD is associated with a higher rate of recurrence (Das et al., 2020). The presence of emboli has also been shown to recognize patients with asymptomatic carotid stenosis and increased risk for stroke (Markus et al., 2010). Although noted in the general population, the significance of such a finding on an annual TCD screening in patients with sickle cell disease is unknown. Methods:At the Medical University of South Carolina, we performed a retrospective review of all patients with SCD who have had TCDs from 2017 to February 2023 and were found to have microemboli to evaluate management and outcome. Results: We have had 5 patients with an incidental finding of microemboli on their annual TCD since 2017. Three were male with median age of 3 (range 2 to 15 years). Four individuals are HbSS genotype. Mean hemoglobin at the time of TCD was 8.26 ± 1.4 g/dL. TCD velocity was normal in four patients at the time of the TCD, while the remaining individual had a low conditional TCD. Two have a previous history of conditional or abnormal TCDs. The location of the microemboli was variable among patients (Table 1). At the time of microemboli findings on TCD, discussions were held with family regarding options for treatment including chronic partial exchange transfusions and optimization of other disease modifying therapies. Management of all patients included MRI at the time of microemboli, which was normal in only two patients. Three patients were started on chronic manual exchange transfusions for 10 months to 3 years. One out of the 3 continued home HU while receiving transfusions while the remainder were transitioned to HU once chronic transfusions were complete. One patient was not started on chronic transfusions but monitored closely with TCDs due to family choice. On follow up, 4 have had repeat TCDs and all have normalized without any subsequent episodes of microemboli. One patient was found to have silent infarct on MRI at time of TCD and 1 has had follow up MRI 4 years after original TCD with a new silent infarct. Of note, this patient had inconsistent follow up with chronic transfusions after initial abnormal TCD. Importantly, none of our 5 patients had an acute symptomatic ischemic event since the microemboli were noted. Overall, among these patients, 2 have had concern for silent infarct and 3 of 5 started on chronic transfusions (Table 1). Conclusion: This is the first report within the literature of microemboli on annual TCD screening in patients with SCD. As this is a new phenomenon, the significance within the disease course is not known for those with sickle cell disease. Identifying patients with microemboli has been used to help navigate the need for early intervention to prevent stroke. Given that individuals with SCD are already at an increased risk for cerebrovascular events, these findings of microemboli could indicate further risk in these individuals as well and deserve further investigation. Further research is warranted as the significance of such a finding is unknown and further understanding could impact the standard of care of this patient population.

The association between blood pressure control and long-term cardiovascular outcomes in Hypertension coexistent with obstructive sleep apnea

PurposeThe goal of blood pressure (BP) control will be lower when hypertensive patients have comorbidities that can affect the risk of cardiovascular diseases. But, the goal of BP control for hypertensive patients coexistent with obstructive sleep apnea (OSA) is not discussed, which is a special population at high risk of cardiovascular diseases.Patients and methodsUsing data from a retrospective study(Urumqi Research on Sleep Apnea and Hypertension (UROSAH) study, we enrolled 3267 participants who were diagnosed with hypertension and performed polysomnography during 2011–2013 to explore the association between BP control and long-term major adverse cardiovascular and cerebrovascular event (MACCE). Outcomes of interest was the levels of BP control, MACCE, cardiac event and cerebrovascular event. Then we calculated the cumulative incidence of MACCE and performed Cox proportional hazards with stepwise models.Results379 of 3267 patients experienced MACCE during a median follow-up of 7.0 years. After full risk adjustment, BP control of 120-139/80-89mmHg was associated with the lowest risk of cerebrovascular event (HR: 0.53, 95%CI:0.35–0.82) rather than MACCE and cardiac event in the total cohort. The association did not change much in patients with OSA. When the SBP and DBP were discussed separately, the SBP control of 120-139mmHg or < 120mmHg was associated with the decreased incidence of MACCE and cerebrovascular event. When DBP control < 80 mm Hg, the risk of cerebrovascular event showed 54% decrease [(HR:0.46, 95%CI: 0.25–0.88)] in patients with hypertension and OSA.ConclusionIn this retrospective study, antihypertensive-drug-induced office and home BP control at 120-139/80-89mmHg showed possible beneficial effect on incident MACCE. However, current results need to be verified in future studies.

Clinical outcomes of comparison between type-III cap and non-cap acute coronary syndrome patients in 3 year follow up

Abstract Background Coronary artery perforation(CAP) is potentially fatal complication of percutaneous coronary intervention(PCI) in acute coronary syndrome(ACS).There is no study in literature comparing long term clinical outcomes of type III-CAP-ACS and non-CAP-ACS patients. Purpose The aim of this study was to investigate in hospital- 1-year and 3-year clinical outcomes of type III-CAP during PCI in ACS patients. Methods Data from ACS patients who had type III-CAP during PCI from January 2010 to Jaunary 2020 at different high volume centers in Turkey were collected.A retrospective cohort of 43,791 patients who underwent PCI was used:120 patients with CAP and 43,671 case-control patients were evaluated.Propensity score matching was used to evaluate the association between differing CAP. Clinical angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively in 1-year and 3-year follow up.Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Results The mean age of subjects was 66.5±11.9 years(61.8%males).Of all ACS patients were 247STEMI(37.9%), 216NSTEMI(33.2%) and 188UA(28.9%).Non significant differences were identified between the CAP and non-CAP groups in hospital follow-up for, cardiac death, major bleeding, and stent thrombosis except cerebrovascular event(p=0.003).At three year, differences remained different between myocardial infarction(MI)(p=0.038),coronary artery bypass graft(CABG)(p=0.001),stent thrombosis(ST)(p=0.002),major bleeding(p=0.029) and cerebrovascular event(CVE)(p=0.011)), was observed in the CAP/non-CAP group.Median follow-up of was 36 months.The all-cause mortality was 33.3% in CAP group versus 1.8% in non-CAP group at 1-year and 28.3% in CAP group versus 6.9% in non-CAP group at 3-years(p=0.001,p=0.001). Conclusions There was no significat difference between type-III-CAP and non-CAP group in hospital mortality.The procedural, clinical, 1 and 3-year outcomes of type III-CAP showed that relatively high risk of MI,CABG,CVE,ST and major bleeding under 1 and 3-year follow-up.Also, non-CAP ACS patients had better survival compared to type III CAP ACS patients in 3- year follow up.Figure 1Figure 2

Intravenous infusion of potassium/magnesium solution for the treatment of postoperative atrial fibrillation after coronary artery bypass graft: a randomized, double-blinded, parallel controlled trial

Abstract Background Postoperative atrial fibrillation (POAF) afflicts 18% of patients following coronary artery bypass graft (CABG), increasing the risk of cerebrovascular events and all-cause mortality by more than three folds. POAF prevention and treatment have remained challenging. Correcting the hydroelectric imbalance before initiating antiarrhythmics (especially potassium and magnesium) is imperative for POAF prevention and management. Nevertheless, the implications of electrolyte infusion among patients with normal electrolyte levels have remained debatable. Methods This randomized, double-arm, double-blind, and parallel clinical trial assessed all patients who developed POAF following isolated CABG for eligibility. Patients were included according to inclusion and exclusion criteria (Figure 1). Permuted block stratified randomization (1:1 ratio) was adopted for randomization. The intervention group received oral metoprolol 47.5 mg combined with the infusion of 10cc potassium (15%) and 4cc magnesium sulfate (50%) diluted in 250cc half-saline serum during 60 minutes. The control group received oral metoprolol 47.5 mg (the standard treatment) and 250 cc half-saline infusion as the placebo. Hemodynamic status and cardiac rhythm were monitored continuously following treatment. Those whose POAF persisted for 6 hours after treatment were administered intravenous amiodarone according to guideline-adherent protocols. Primary outcomes were AF persistence (during the first six hours) and AF recurrence (during 48 hours after cardioversion). Intention-to-treat (ITT) analysis was used to assess the intervention effects. Secondary outcomes included time to cardioversion (in the first six hours), rate control achievement (rate&amp;lt;110 beats/min achieved in the first three hours), and time to cardioversion after amiodarone administration. Results Seventy-two patients were enrolled in the study, with 38 (65.05±7.65 years, 73.7% men) in the intervention and 34 patients (65.24±7.35 years, 67.6% men) in the control group. The two groups were comparable regarding demographics, medical history, electrolyte levels, and intra- and postoperative characteristics. In the intervention and control groups, 16 (42.1%) and 16 (47.1%) patients had AF persistence, respectively (P-value:0.67). Respective figures for AF recurrence were 10 (26.3%) and 13 (38.2%) patients (P-value: 0.28). ITT analysis indicated that potassium/magnesium infusion did not significantly reduce AF persistence (relative-risk (RR): 0.89, 95% confidence interval (CI): 0.53-1.49) or AF recurrence (RR: 0.68, 95%CI: 0.35-1.36). Likewise, secondary outcomes did not differ significantly between the intervention and control groups (all Ps&amp;gt;0.2) (Figure 1). Conclusion Among patients with normal electrolyte levels, potassium and magnesium infusion did not reduce the risk of AF persistence or recurrence compared to the standard treatment (beta blockers).Figure 1.Study design and findings

Progressive mechanical and structural changes in anterior cerebral arteries with Alzheimer’s disease

Alzheimer's disease (AD) is a neurodegenerative disease and the main cause for dementia. The irreversible neurodegeneration leads to a gradual loss of brain function characterized predominantly by memory loss. Cerebrovascular changes are common neuropathologic findings in aged subjects with dementia. Cerebrovascular integrity is critical for proper metabolism and perfusion of the brain, as cerebrovascular remodeling may render the brain more susceptible to pulse pressure and may be associated with poorer cognitive performance and greater risk of cerebrovascular events. The objective of this study is to provide understanding of cerebrovascular remodeling with AD progression. Anterior cerebral arteries (ACAs) from a total of 19 brain donor participants from controls and pathologically diagnosed AD groups (early—Braak stages I-II; intermediate—Braak stages III-IV; and advanced—Braak stages V-VI) were included in this study. Mechanical testing, histology, advanced optical imaging, and mass spectrometry were performed to study the progressive structural and functional changes of ACAs with AD progression. Biaxial extension-inflation tests showed that ACAs became progressively less compliant, and the longitudinal stress in the intermediate and advanced AD groups was significantly higher than that from the control group. With pathological AD development, the inner and outer diameters of the ACAs remained almost unchanged; however, histology study revealed progressive smooth muscle cell atrophy and loss of elastic fibers which led to compromised structural integrity of the arterial wall. Multiphoton imaging demonstrated elastin degradation at the media-adventitia interface, which led to the formation of an empty band of 21.0 ± 15.4 μm and 32.8 ± 9.24 μm in width for the intermediate and advanced AD groups, respectively. Furthermore, quantitative birefringence microscopy showed disorganized adventitial collagen with AD development. Mass spectrometry analysis provided further evidence of altered collagen content and other extracellular matrix (ECM) molecule and smooth muscle cell changes that were consistent with the mechanical and structural alterations. Collectively, our study provides understanding of the mechanical and structural cerebrovascular deterioration in cerebral arteries with AD, which may be related to neurodegenration and pathology in the brain.

Ischemic stroke secondary to radiation-induced carotid artery stenosis

Large vessel vasculopathy, such as carotid stenosis, has been shown to be a side effect of radiotherapy (RT) and has received increasing attention especially in recent decades with the improvement of RT technology. These injuries can lead to a higher risk of cerebrovascular events such as ischemic stroke. The management of these lesions may be performed with surgical repair but also with endovascular technique. A 61-year-old man was admitted to the emergency department for an acute ischemic stroke. He was treated 16years prior for laryngeal tumor for which he had received 23 sessions of radiation therapy at the dose of 60Gy per session. The CT scan showed a radiation-induced stenosis of the right internal carotid artery with thrombosis of the right anterior cerebral artery and the right middle cerebral artery. The patient was treated with angioplasty of the right internal carotid artery with good outcome. Radiation-induced vasculopathy of the carotid artery has gained relevance in patients with head and neck neoplasms. These vascular lesions are associated with the risk of late cerebrovascular events.

Sex differences in major adverse cardiovascular and cerebrovascular event risk among central retinal artery occlusion patients

To estimate the association between central retinal artery occlusion (CRAO) and major adverse cardiovascular and cerebrovascular events (MACCE), including their clinical characteristics, blood markers, and the contribution of CRAO to MACCE, as well as to assess any sex differences. This retrospective cohort study included continuous new-onset CRAO patients and 1:4 controls during the same period. Correlations of CRAO with the incidence of MACCE during follow-up and the sex-related differences were studied. One hundred and twenty-four CRAO patients and four hundred and ninety-six controls were enrolled. Neutrophil-to-lymphocyte ratio (NLR, P = 0.014) and high-sensitivity C-reactive protein (hs-CRP, P = 0.038) were tended to be higher in CRAO patients. After the follow-up period, 78 patients experienced MACCE. Multivariate Cox regression analysis showed that CRAO was a predictor of the occurrence of MACCE (HR 2.321, 95% CI 1.439–3.744, P = 0.001). Sex subgroups indicated that age, diabetes, current smoking, CRAO, NLR and hs-CRP increased the risk factor of MACCE in males (All P < 0.05) and CRAO, NLR, low-density lipoprotein cholesterol (LDL-C) and hs-CRP were independent influencing factors for females (All P < 0.05). New-onset CRAO significantly increases the probability of MACCE and is associated with a poor prognosis. The sex-related differences suggested that effective prevention of the occurrence of MACCE in high-risk patients requires that attention be given to individualized risk factors corresponding to sexes.