Risk Of Subsequent Stroke Research Articles

Abstract 47: Using Ultrasound and Inflammation to Improve Prediction of Ischemic Stroke: A Secondary Analysis of MESA

Background: The Multi-Ethnic Study of Atherosclerosis (MESA) is a large prospective epidemiologic study of the clinical factors that can predict transition from asymptomatic to symptomatic cardiovascular disease. Although prior studies have looked at ischemic stroke, they have not systematically examined the relationship between baseline ultrasound and inflammation measurements and subsequent primary stroke risk. Methods: The primary outcome is incident ischemic stroke during follow-up. The predictors are 9 ultrasound-derived measurements and 5 serum measurements related to inflammation. We fit Cox models to ischemic stroke and adjusted for patient age, hypertension, diabetes, total cholesterol, and smoking. Using DeLong’s method, we compared the AUC of the baseline adjusted model to the AUC of the model with predictor variables that were significant in the Cox models, to determine if they improved stroke prediction. Results: We included 6,095 patients with an average age of 61.9 years. The primary outcome of ischemic stroke was seen in 107 patients (1.8%) and the mean follow-up time was 7.7 years. In the Cox models, we found that small artery elasticity (SAE), carotid distensibility (CD), carotid stenosis (CS), and interleukin-6 (IL6) were associated with incident stroke. The AUC of the baseline model to predict stroke, which included patient age, hypertension, diabetes, total cholesterol, and smoking, was 0.745. When we added tertiles of SAE, CD, IL6 and categories of CS, the AUC improved to 0.765 (p=0.021 for difference). Conclusions: In a multiethnic cohort of patients without CVD at baseline, we found several ultrasound measurements and a serum marker of inflammation which predicted the occurrence of a primary ischemic stroke. Adding these basic ultrasound and serum measurements significantly improved the prediction of stroke, which could have implications for primary prevention efforts.

Abstract WP234: Association of Social Trust With Subsequent Stroke and Cardiovascular Disease Risk

Introduction: Although social capital has been shown to be one of the important social determinants of health, the association between social trust and the risk of stroke and cardiovascular disease (CVD) is not clear yet. We aimed to investigate the association of social trust with stroke and CVD risk using a large Asian population. Methods: The study data was derived from the Korean National Health Insurance Service database. Community-level social trust was determined from the Koran Community Health Survey. The study population consisted of 2,156,829 participations. According to social trust index measured in the area of residence during 2011, participants were followed-up from 1 January 2012 to 31 December 2016. Multivariate Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for stroke and CVD risk according to quintiles of social trust. Results: Compared to those with the lowest quintile of social trust, participants within the highest quintile had lower risk for stroke (aHR 0.90, 95% CI 0.87-0.93) and CVD (aHR 0.91, 95% CI 0.89-0.93), and the risk-reducing association of high social trust on CVD risk was preserved after additional adjustments for lifestyle behaviors including smoking, alcohol intake, and physical activity. Conclusion: Higher social trust was associated with reduced risk of stroke and CVD even after considering lifestyle behaviors. Social trust in a community level is an important determinant of stroke risk and enhancing social trust may lead to reduced risk of stroke and CVD.

The significance of Holter electrocardiography in the etiological evaluation of transient ischemic stroke.

BACKGROUND:Transient ischemic attack (TIA) is a common neurovascular disorder associated with a higher risk of stroke within the first 24 h after the first event. Acute cerebral and arterial neuroimaging combined with long-term electrocardiography (ECG) monitoring have been proven to be useful in determining etiology. Cardio-embolism constitutes 20%–26% etiology of TIAs most of them with atrial fibrillation (AF). Investigation of AF after TIA is very important because oral anticoagulants can reduce the risk of subsequent stroke by two thirds.MATERIALS AND METHODS:The present study included 45 patients suffering from TIA with undetermined source according to the Trial of Org 10172 in Acute Stroke Treatment criteria; the control group (n = 45) was selected from the patients admitted to cardiology outpatient clinic with nonspecific complaints without cerebrovascular and/or cardiovascular disease. All patients underwent echocardiography and 24 h Holter ECG monitoring (HM).RESULTS:There was no significant difference between the patient group and the control group in terms of age and gender. Cholesterol, low-density lipoprotein and urea levels, left atrium diameters and the incidence of hypertension, coronary artery diseases, and AF were significantly higher in TIA group (P < 0.05). In the results of HM, there were six patients with AF in the study group, and in the control group, there was no patients with AF (P = 0.03).DISCUSSION AND CONCLUSION:In acute phase of TIA, 24 h HM is important for determining the etiology and selecting an appropriate treatment that can protect patients from subsequent strokes.

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial

We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

Retinal artery occlusion does not portend an increased risk of stroke

ObjectiveThe aim of this study was to determine the subsequent risk of stroke after a diagnosis of retinal artery occlusion (RAO). We hypothesized that the risk would be low and comparable to that of the general population. RAO is relatively rare and often incorrectly diagnosed. We believe our institution is in a unique position to investigate this relationship with both a high-volume eye center and vascular laboratory. MethodsThis was a retrospective, single-institution review of 221 patients diagnosed with RAO from 2004 to 2018, confirmed with fluorescein angiography. Demographics, comorbidities, imaging of the carotid arteries, and prospective events, such as stroke, myocardial infarction (MI), and death, were recorded. Time to first stroke, first MI, and death was estimated using Kaplan-Meier estimation separately and as a composite end point. ResultsThere were 221 patients identified with a confirmed diagnosis of RAO. The mean age in the cohort was 66.1 years; 53% of patients were male, and 29% were diabetic. Median length of follow-up was 2.2 years. Five patients (2.3%) had a documented stroke; four of the five strokes occurred at the time of RAO, with one that was contralateral occurring at 1.2 years. There were eight MIs (3.6%) in the cohort, two of which resulted in death. Twenty-two patients (10%) experienced a stroke, MI, or death. There were 141 (63.8%) patients who had carotid imaging performed, of whom 20 (14.2%) were found to have >50% stenosis. ConclusionsThe rate of stroke in patients with confirmed RAO was 2.3%; however, excluding concurrent ischemic events, the risk was <1%. The incidence of carotid artery stenosis >50% was 14.2%. The authors conclude that the risk of stroke after confirmed RAO is lower than previously reported and comparable to prior population-based studies of all at-risk adults.

Substitutions of Oatmeal and Breakfast Food Alternatives and the Rate of Stroke.

Background and Purpose- Studies indicate that consuming breakfast every day, and particularly oatmeal, is associated with lower risk of stroke. However, few studies have considered replacement foods when considering foods usually consumed at breakfast. We, therefore, aimed to model substitutions between the breakfast food products oatmeal, eggs, yogurt, or white bread and subsequent risk of stroke. Methods- Participants from the Danish cohort study (Diet, Cancer and Health; n=55 095) were followed for 13.4 years, during which 2260 subjects experienced a first-ever stroke. Breakfast foods were assessed using a validated 192-item food-frequency questionnaire at baseline. Cox proportional hazards models were used to estimate adjusted hazard ratios and 95% CIs for associations between hypothetical substitutions of standard portion sizes of breakfast foods and stroke. Results- Modeling replacement of white bread or eggs with oatmeal was associated with a lower rate of total stroke (hazard ratio [HR]=0.96 [95% CI, 0.95-0.98]; HR=0.96 [95% CI, 0.93-0.98], respectively), total ischemic stroke (HR=0.96 [95% CI, 0.94-0.98]; HR=0.96 [95% CI, 0.94-0.99], respectively), and ischemic stroke due to small-artery occlusion (HR=0.95 [95% CI, 0.93-0.98]; HR=0.95 [95% CI, 0.91-0.99], respectively). Furthermore, modeling replacement of eggs with oatmeal was associated with a lower rate of total hemorrhagic stroke (HR=0.94 [95% CI, 0.89-0.99]). Modeling replacement of yogurt with oatmeal was not associated with stroke. Conclusions- Our findings suggest that a diet containing oatmeal instead of white bread or eggs may be associated with a lower rate of stroke.

Assessment of Cardiovascular Risk by the Combination of Clinical Risk Scores Plus Platelet Expression of FcγRIIa

Platelet expression of FcγRIIa was quantified after myocardial infarction (MI) and we found that patients with high platelet FcγRIIa expression (>11,000/platelet) had a fourfold greater risk of subsequent MI, stroke, and death. This analysis of the original cohort of 197 patients was designed to determine whether platelet expression of FcγRIIa could be used in combination with clinical risk scores (GRACE [Global Registry of Acute Coronary Events] and DAPT [Dual Antiplatelet Therapy]) to refine cardiovascular risk assessment. Platelet expression of FcγRIIa quantified with the use of flow cytometry was broadly distributed in patients stratified into high and low risk groups based on clinical risk scores. In patients identified as high risk by the GRACE score, 62% had high platelet FcγRIIa expression. Similarly, in patients identified as high risk by DAPT, 55% had high platelet FcγRIIa expression. High platelet FcγRIIa expression discriminated high and low risk cohorts in patients with high cardiovascular risk defined by either the GRACE score (high platelet FcγRIIa 18.9% vs low platelet FcγRIIa 0%; odds ratio = 15.7, p = 0.06) or the DAPT score (high platelet FcγRIIa 15.4% vs low platelet FcγRIIa 3.7%; odds ratio = 5.6, p = 0.03) assessment. Platelet expression of FcγRIIa merits additional study to determine whether low platelet FcγRIIa expression can be used to guide early transition to aspirin monotherapy and high platelet FcγRIIa expression can be used to guide continuation of DAPT.

Lifestyle behaviours in patients with established cardiovascular diseases: a European observational study

BackgroundPatients who have experienced a cardiovascular clinical event such as a myocardial infarction or stroke qualify for intensive risk factor evaluation and management.The aim of this study is to explore lifestyle changes as well as the achievement of targets for risk factors in patients with established cardiovascular disease.MethodsCross-sectional study conducted in primary care practices. The study was carried out in six European countries (Croatia, France, Portugal, Slovenia, Spain and Turkey). Patients with established cardiovascular disease (coronary heart disease and stroke) attended in primary care were selected and assessed from January to June 2016. Patients were recruited and assessed at the practice by research assistants between 6 months and 3 years after the event. Statistical comparisons were done with the unpaired two-sided Student’s t-test for continuous variables and Chi-square test for categorical variables.ResultsNine hundred and seventy-three patients (32.4% females) were assessed. About 14% of them were smokers, 32% were physically inactive, and 30% had nutritionally poor eating behaviours. LDL cholesterol target value below 70 mg/dl was achieved in about 23% of patients, and in general, women were less cardio-protected by drugs than men.ConclusionsMany patients with established cardiovascular disease who attended in general practice still fail to achieve the lifestyle, risk factor, and therapeutic targets set by European guidelines. These results are relevant to general practitioners because these patients have a high risk of subsequent cardiovascular events, including MI, stroke, and death.

Symptomatic menopausal transition and risk of subsequent stroke.

ObjectiveTo examine the long-term risk of stroke in women who have experienced symptomatic menopausal transition.MethodsIn this nationwide, population-based cohort study conducted from January 1, 2000 to December 31, 2013, we identified 22,058 women with no prior history of stroke, who experienced symptomatic menopausal transition at ≥45 years of age. Moreover, 22,058 women without symptomatic menopause were matched by propensity scores and enrolled as a comparison group. The propensity score was calculated by using all characteristic variables of each subject, including demographics (age and monthly income), comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, chronic kidney disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, dysrhythmia, peripheral artery occlusive disease), Charlson’s comorbidity index score, clinic visit frequency, and long-term medications (antihypertensives, antidiabetic agents, statins, antiplatelets, aspirin, warfarin, and hormone replacement therapy). The primary endpoint was the development of stroke after the onset of symptomatic menopausal transition. The Fine and Gray’s proportional subhazards model was performed to assess the association between symptomatic menopausal transition and subsequent stroke. All subjects were followed up until December 31, 2013.ResultsDuring a mean follow-up of 8.5 years (standard deviation 4.7 years, maximum 14 years), 2,274 (10.31%) women with symptomatic menopausal transition, and 1,184 (5.37%) matched comparison participants developed stroke. The incidence rates were 11.17 per 1,000 person-years in the symptomatic menopausal transition group compared with 8.57 per 1,000 person-years in the comparison group. The risk of developing stroke was significantly higher in women with symptomatic menopausal transition (crude subhazard ratio, 1.31; 95% confidence interval (CI) [1.22–1.41]; P < 0.001). After adjusting for demographics, comorbidities, clinic visit frequency, and long-term medications, the risk of stroke remained statistically significant (adjusted subhazard ratio, 1.30; 95% CI [1.21–1.40]; P < 0.001). Moreover, subgroup analyses revealed no evidence for inconsistent effects for symptomatic menopausal transition on subsequent risk of stroke across all subgroups except age, comorbidities, hypertension, and use of antihypertensives. Women with early menopausal transition (before age 50), without comorbid condition, without hypertension, or without use of antihypertensives are at a higher risk of stroke. The longer duration of symptomatic menopausal transition was associated with higher risk of stroke (P for trend < 0.001).ConclusionIn this large-scale retrospective cohort study, symptomatic menopausal transition was statistically significantly associated with a 30% increased risk of stroke. Further prospective studies are required to confirm our findings.

Association of Total Reproductive Years With Incident Atrial Fibrillation, and Subsequent Ischemic Stroke in Women With Natural Menopause.

The association of lifetime exposure to endogenous sex hormone with incident atrial fibrillation (AF) and subsequent ischemic stroke has never been studied. This study involved 4 638 299 natural postmenopausal waomen aged ≥40 years without prior history of AF and with national breast cancer check-up between January 1, 2009 and December 31, 2014. The primary end point was incident AF, and the secondary end point was subsequent ischemic stroke once AF has developed. Cox proportional hazard regression analysis was used to estimate the risk of end points. During the mean follow-up of 6.3 years, shorter total reproductive years (<30 years) were associated with 7% increased risk of AF after adjusting for confounding variables (adjusted hazard ratio [aHR], 1.07 [95% CI, 1.05-1.09]). Risk of AF declined progressively with every 5-yearly increment in total reproductive years (P-for-trend <0.001). However, the prolonged (≥2 years) use of hormone replacement therapy after menopause was paradoxically associated with a 3% increase in AF risk (aHR, 1.03 [95% CI, 1.01-1.05]). For the secondary end point analysis, the risk of ischemic stroke after AF development significantly decreased with each 5-yearly increment in total reproductive years (with <30 years as reference; aHR, 0.93 [95% CI, 0.88-0.99] for 30-34 years; aHR, 0.84 [95% CI, 0.79-0.89] for 35-39 years; and aHR, 0.88 [95% CI, 0.80-0.97] for ≥40 years, P-for-trend <0.001). In women with natural menopause, shorter lifetime exposure to endogenous sex hormone, that is, shorter total reproductive years, was significantly associated with a higher risk of AF and subsequent ischemic stroke. Paradoxically, prolonged exogenous hormone replacement therapy increased the risk of incident AF.

P2756Risk of stroke subsequent to infective endocarditis: a nationwide study

Abstract Background Patients with infective endocarditis (IE) are at high risk of cerebral embolization, however little is known about the risk of stroke subsequent to IE in patients with stroke during IE admission. Purpose To investigate the risk of stroke after discharge of IE in patients with stroke during IE admission compared with patients without stroke during IE admission. Methods Using Danish nationwide registries we identified non-surgically treated patients with IE discharged alive, in the period 1996–2016. The study population was grouped in 1) patients with stroke during IE admission and 2) patients without stroke during IE admission. Crude cumulative risk of stoke were calculated using the Aalen-Johansen estimator accounting for death as a competing risk. Multivariable adjusted Cox proportional hazard analysis was used to compare the associated risk of stroke between groups. We identified differentials in the associated risk of stroke during follow-up between groups (p=0.006 for interaction with time), and follow-up was split into 0–1 year and 1–5 years time periods. Results We identified 4,284 patients with IE, 239 patients (5.6%) with stroke during IE admission (median age: 71.9 years, 58.2% males), and 4,045 patients (94.4%) without stroke during IE admission (median age 69.7 years, 64.8% males). The crude cumulative risk of stroke within 1 year of follow-up is shown in Figure Panel A, and with 1 to 5 years of follow-up in Figure Panel B. In multivariable adjusted analyses, the associated risk of stroke was higher in patients with stroke during IE admission within a follow-up period of 1 year, HR 3.21 (95% CI: 1.66–6.20) compared with patients without stroke during IE admission. From 1 to 5 years of follow-up, we identified no difference in the associated risk of stroke between groups, HR 0.91 (95% CI: 0.33–2.50). Cumulative incidence of stroke Conclusion Non-surgically treated patients with IE who had a stroke during IE admission were at significantly higher associated risk of subsequent stroke – although not significant beyond 1 year after discharge from IE. These findings underline the need for identification of causes and mechanisms of recurrent strokes after IE to develop preventive means.

Risk of Recurrent Bleeding Events in Nonvalvular Atrial Fibrillation Treated with Vitamin K Antagonists: A Clinical Practice Research Datalink Study.

Background There is little evidence on how the occurrence of a bleed in individuals on vitamin K antagonists (VKAs) impacts the risk of subsequent bleeds, and thromboembolic and ischemic events. Such information would help to inform treatment decisions following bleeds. Objective To estimate the impact of bleeding events on the risk of subsequent bleeds, venous thromboembolism (VTE), stroke, and myocardial infarction (MI) among patients initiating VKA treatment for new-onset nonvalvular atrial fibrillation (NVAF). Methods We conducted an observational cohort study using a linked Clinical Practice Research Datalink—Hospital Episode Statistics dataset. Among a cohort of individuals with NVAF, the risk of clinically relevant bleeding, VTE, stroke, and MI was compared between the period prior to the first bleed and the periods following each subsequent bleed. The rate and cost of general practitioner (GP) consultations, prescriptions, and hospitalizations were also compared across these periods. Results The risk of clinically relevant bleeding events was observed to be elevated at least twofold in all periods following the first bleeding event. The risk of VTE, stroke, and MI was not found to differ according to the number of clinically relevant bleeding events. The rate and cost of GP consultations, GP prescriptions, and hospitalizations were increased in all periods relative to the period prior to the first bleed. Conclusions The doubling in the risk of bleeding following the first bleed, taken alongside the stable risk of MI, VTE, and stroke, suggests that the risk–benefit balance for VKA treatment should be reconsidered following the first clinically relevant bleed.

P4994Severe hypoglycemia: a marker for worse cardiovascular outcomes? A meta-analysis of randomised controlled trials

Abstract Background Observational data have suggested that severe hypoglycemic events increase the risk of subsequent cardiovascular morbidity and mortality but the evidence from randomised studies has been inconsistent. Purpose This meta-analysis evaluates the relationship between severe hypoglycemic events (SHEs) and the subsequent risk of mortality and major adverse cardiovascular events (MACE). Methods PubMed, Embase, and Cochrane Central databases were searched for randomised controlled trials (RCTs) that reported cardiovascular outcomes in patients with diabetes with a history of SHE. Treatment effects and relative standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis via generic inverse variance method. Results Data from 9 RCTs and 3,462 randomised patients were available. Patients, who suffered a SHE, were found to have a significantly increased risk of subsequent all-cause mortality (HR 2.24; 95% CI 1.70, 2.95; p-value &lt;0.01), cardiovascular mortality (HR 2.32; 95% CI 1.67, 3.22; p-value &lt;0.01), and MACE (HR 1.66; 95% CI 1.35, 2.06; p-value &lt;0.01) compared to the patients without a SHE. An increased risk of subsequent stroke and arrhythmic death (p-value&lt;0.05) were also found. There was no significant association between SHE and the risk of subsequent myocardial infarction and hospitalisation for unstable angina or heart failure. Predictors of severe hypoglycemia Older age, Lower weight, Insulin-treated, CKD, Neuropathy, previous CVD Older age, Females, Lower weight, Insulin-treated, Longer duration of diabetes, CKD, Previous CVD Older age, Females, Lower weight, Insulin-treated, Longer duration of diabetes, CKD, Previous CVD Older age, Females, Insulin-treated, Longer duration of diabetes, CKD Older age, Females, Lower weight, Insulin-treated, CKD Older age, Lower weight, Longer duration of diabetes, CKD, Poor cognition, Previous CVD CKD = Chronic kidney disease; CVD = Cardiovascular disease. Conclusion In patients with diabetes, the occurrence of a SHE was associated with a significantly increased risk of subsequent cardiovascular morbidity and mortality. Further studies are required to explore and circumvent the predictors of SHEs in these patients. Acknowledgement/Funding None

The Relationship between Scabies and Stroke: A Population-Based Nationwide Study

Background: Scabies is a commonly occurring infectious skin infestation that substantially impacts the quality of life, while stroke, which consists of a neurological deficit resulting from a lack of blood flow to the brain, carries sizable economic costs. The pathophysiologic mechanisms underlying both diseases involve inflammatory processes that are mediated by the immune system; however, no prior research has been conducted to explore the relationship between the two conditions. Methods: This population-based nationwide study utilized data from the National Health Insurance Research Database (NHIRD) of Taiwan for a total of 6628 scabies patients, who comprised a scabies group, and a randomly selected cohort of 26,509 matching patients, who served as a control group. More specifically, the medical records for the patients in both groups were checked for seven years to identify any new cases of stroke within that seven-year follow-up period. The hazard ratio (HR) of stroke for the follow-up period was then calculated using Cox proportional hazards regressions, while comorbidities and demographic characteristics were likewise analyzed. Results: During the follow-up period, 2892 patients, or 8.7%, of the overall total of 33,137 patients included in the study were newly diagnosed with a stroke. Of those newly diagnosed stroke patients, 833 were from the scabies group, and 2059 were from the control group, accounting for 12.6% and 7.8%, respectively, of the individuals in each group. With a crude hazard ratio of 1.67, the patients in the scabies group had a significantly higher risk of subsequent stroke than those in the control group, although the adjusted hazard ratio (aHR) for the scabies patients, which was determined by adjusting for covariates, was only 1.32 (95% confidence interval (CI): 1.21–1.43). Conclusions: The results of the study indicated an elevated risk of stroke among scabies patients, an association that might be contributed to by immunopathological factors. This information could serve as a reminder to clinicians to remain alert to any indications of neurological impairment in patients previously infected with scabies.

Association of LVAD Outflow Cannula Position with Stroke Risk

Background Stroke remains a major cause of morbidity and mortality in patients with left ventricular assist devices (LVAD). Although several studies have delineated clinical risk factors for development of stroke, it is not entirely clear whether changes in position/orientation of the LVAD cannula impact incidence of subsequent stroke. Hypothesis We hypothesized that variations in surgical implant techniques for LVAD inflow and outflow cannula positions impact the subsequent risk of stroke. Methods We conducted a retrospective review of all patients that underwent LVAD implantation at our institute between 2011 and 2016. All patients that underwent multi detector cardiac computed tomography (MDCT) were included in the analysis. Patients with non-contrast CT scans and poor imaging quality were excluded. Baseline demographic as well as clinical parameters were obtained for all patients. Inflow and outflow cannula positions were assessed by various MDCT parameters outlined in table 1. The incidence of stroke from time of implantation to one year post-LVAD implantation was obtained. Results A total of 311 continuous-flow LVADs were implanted at our hospital from 2011-2016, of which 75 patients met inclusion criteria for the study. The study population was predominantly HM II with only 3 HVAD and 1 HM 3 patients. 11 patients had stroke within 1 year of LVAD implantation. There were no significant differences in baseline demographic or clinical characteristics between patients that had stroke versus those that did not. Patients with stroke had more acute angulation of outflow cannula relative to the aorta compared to patients without stroke (42⁰ versus 65⁰ respectively, p= 0.026). In addition, patients with stroke had a smaller diameter of anastomosis of the outflow cannula compared to those without stroke (1.3 cm versus 1.5 cm respectively, p= 0.013). The inflow cannula position did not impact incidence of stroke. Conclusions Our study shows that LVAD outflow cannula orientation and size of anastomosis portend a higher risk of subsequent stroke. Therefore, it is imperative to optimize LVAD surgical implant techniques and device manufacturing to allow larger anastomosis site and less acute angulation of the outflow cannula.

Association Between Warfarin Control Metrics and Atrial Fibrillation Outcomes in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation

Bleeding and thrombotic events (eg, stroke and systemic embolism) are common in patients with atrial fibrillation (AF) taking warfarin sodium despite a well-established therapeutic range. To evaluate whether history of therapeutic warfarin control in patients with AF is independently associated with subsequent bleeding or thrombotic events. In this multicenter cohort study of 176 primary care, cardiology, and electrophysiology clinics in the United States, data were obtained during 51 830 visits among 10 137 patients with AF in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry; 5545 patients treated with warfarin were included in the bleeding analysis, and 5635 patients were included in the thrombotic event analysis. Patient follow-up was performed from June 29, 2010, to November 30, 2014. Data analysis was performed from August 4, 2016, to February 15, 2019. Multiple measures of warfarin control within the preceding 6 months were analyzed: time in therapeutic range of 2.0 to 3.0, most recent international normalized ratio (INR), percentage of time that a patient had interpolated INR values less than 2.0 or greater than 3.0, INR variance, INR range, and percentage of INR values in therapeutic range. Association of INR measures, alone or in combination, with clinical factors and risk for thrombotic events and bleeding during the subsequent 6 months was assessed post hoc using logistic regression models. A total of 5545 patients (mean [SD] age, 74.5 [9.8] years; 3184 [57.4%] male) with AF were included in the major bleeding analysis and 5635 patients (mean [SD] age, 74.5 [9.8] years; 3236 [57.4%] male) in the thrombotic event analysis. During a median follow-up of 1.5 years (interquartile range, 1.0-2.5 years), there were 339 major bleeds (6.1%) and 51 strokes (0.9%). Multiple metrics of warfarin control were individually associated with subsequent bleeding. After adjustment for clinical bleeding risk, 3 measures-time in therapeutic range (per 1-SD increase ≤55: adjusted odds ratio [aOR], 1.16; 95% CI, 1.02-1.32), variation in INR values (aOR, 1.32; 95% CI, 1.19-1.47), and maximum INR (aOR, 1.20; 95% CI, 1.10-1.31)-remained associated with bleeding risk. Adding INR variance to a clinical risk model slightly increased the C statistic from 0.68 to 0.69 and had a net reclassification improvement index of 0.028 (95% CI, -0.029 to 0.067). No INR measures were associated with subsequent stroke risk. Three metrics of prior warfarin control were associated with bleeding risk but only marginally more so than traditional clinical factors. This study did not identify any measures of INR control that were significantly associated with stroke risk.

Sleep Disorders and Stroke: Does Treatment of Obstructive Sleep Apnea Decrease Risk of Ischemic Stroke?

This review aims to support obstructive sleep apnea (OSA) as a risk factor for ischemic stroke, review treatment strategies for OSA, provide a comprehensive review of clinical data on OSA treatment and ischemic stroke risk, and to critically assess if treatment of OSA decreases the risk of ischemic stroke and if treatment improves outcomes and subsequent ischemic stroke risk in post-stroke patients. Several observational studies, randomized controlled trials (RCTs), and meta-analyses have examined the risk of ischemic stroke and cardiovascular events in patients with OSA and have also examined continuous positive airway pressure (CPAP) treatment in these patients. Observational studies have shown an increased risk of ischemic stroke in patients with untreated OSA when compared with patients treated with CPAP; however, results are not statistically significant. RCTs and meta-analyses have shown no significant ischemic stroke risk reduction in CPAP treated patients with OSA. Several studies have shown improved outcomes in post-stroke patients with OSA treated with CPAP; however, few data is available for subsequent ischemic stroke risk reduction. Further research is needed for surgical treatment of OSA and assessment of ischemic stroke risk. OSA is associated with increased risk of ischemic stroke, and OSA should be treated with the appropriate therapy. While the current data is promising, more studies are necessary to state whether treatment of OSA reduces ischemic stroke risk and subsequent ischemic stroke risk. A practical approach to the sleep disorder evaluation and treatment of patients with cerebrovascular disease is outlined.

Residual vegetation after treatment for left-sided infective endocarditis and subsequent risk of stroke and recurrence of endocarditis

BackgroundLittle is known about the subsequent risk of stroke and recurrence of IE for patients surviving infective endocarditis (IE) with a residual vegetation at discharge. MethodsPatients were consecutively included in the East Danish Endocarditis Registry from 2002 to 2012. We included patients undergoing medical treatment only during IE admission who were discharged alive. Size of residual vegetation was assessed by echocardiography at discharge and patients were categorized according to median length of residual vegetation. Using multivariable adjusted Cox Proportional hazard analysis, we assessed the associated risk of stroke and recurrence of IE between study groups. ResultsAmong 915 IE patients, 305 were included after selection criteria were applied, 151 patients without residual vegetation, 73 patients with 1–5 mm residual vegetation, and 81 patients with >5 mm residual vegetation. We identified an increased associated risk of stroke for patients with 1–5 mm and > 5 mm residual vegetation, HR = 0.88 (95% CI: 0.26–2.94) and HR = 2.95 (95% CI:1.18–7.34) compared with patients without residual vegetation. No difference was seen between groups for the associated risk of recurrence of IE, HR = 1.39 (95% CI: 0.91–2.13) and HR = 1.38 (95% CI: 0.91–2.10) for patients with a residual vegetation 1–5 mm and > 5 mm compared with patients without residual vegetation. ConclusionsPatients surviving IE with a residual vegetation > 5 mm had an increased associated risk of stroke compared with patients without residual vegetation. These findings provide new perspectives on a patient group sparsely describe, suggesting a potential benefit of therapy among patients surviving IE with a residual vegetation > 5 mm.

An attempt to explain the bidirectional association between ischaemic heart disease, stroke and depression: a cohort and meta-analytic approach.

Depression and cardiovascular diseases (CVDs) are common diseases and associated in a bidirectional manner. To examine whether a bidirectional association between CVD and depression could be explained by shared risk factors, misclassification of disease measures or non-response. A total of 10 population-based cohorts including 93 076 men and women (mean age 54.4 years, s.d. = 9.2) and an additional 10 510 men (mean age 51.2 years, s.d. = 0.3) were followed for subsequent depression, ischaemic heart disease (IHD) and stroke in the Danish National Patient Registry from health examinations between 1982 and 2015 and until end of follow-up in 2017-2018. Exposures were physicians' diagnoses of IHD, stroke, depression or self-reported chest pain, depression, use of antidepressant medication and the Major Depression Inventory at the time of study entry in the Metropolit study. Associations were analysed using Cox proportional hazard regression with disease as time-dependent variables. IHD and stroke were associated with subsequent depression (hazard ratio (HR) for IHD: 1.79, 95% CI 1.43-2.23 and HR for stroke: 2.62, 95% CI 2.09-3.29) and the associations were present in both men and women. Adjustment for the shared risk factors socioeconomic status, lifestyle, body mass index, statin use and serum lipids did not change the risk estimates. Furthermore, depression was associated with higher risk of subsequent IHD (HR = 1.63, 95% CI 1.36-1.95) and stroke (HR = 1.94, 95% CI 1.63-2.30). The associations were also present when the analyses were based on self-reported disease measures or restricted to include non-responders. The bidirectional association between CVD and depression was not explained by shared risk factors, misclassification or non-response.

Use of Chinese herbal medicines by rheumatoid arthritis patients was associated with lower risk of stroke: A retrospective cohort study

Background and purposeRheumatoid arthritis (RA) patients have increased risk of developing stroke. The use Chinese herbal medicines (CHMs) is increasing, but whether they can reduce the risk of developing stroke remains unclear. We conducted a longitudinal cohort study to compare the effect of CHMs use on the subsequent stroke risk in RA individuals. Materials and methodsUsing claims data from the National Health Insurance of Taiwan, we identified 7925 newly-diagnosed RA patients with no history of previous stroke who were 20 years of age or older between 1998 and 2010. From this sample, we enrolled 3134 CHMs users and 3134 non-CHMs users, randomly selected using propensity scores matching from the remaining cases. They were followed until the end of 2012 to record stroke incidence. A Cox proportional hazards regression model was used to compute the hazard ratio of stroke with regard to CHMs use. ResultsDuring the follow-up, 299 CHMs users and 395 non-CHMs users developed stroke, representing incidence rates of 10.94 and 16.69, respectively, per 1000 person-years. CHMs use was associated with 38% (adjusted HR: 0.62; 95% confidence interval: 0.54-0.73) lower subsequent risk of stroke. The most prominent effect was observed in those receiving CHMs for over two years. The following seven commonly-prescribed CHMs were found to lessen the stroke risk: Dan-Shen, Tian-Hua-Feng, Fu-Zi, Shao-Yao-Gan-Cao-Tang, Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, and Gui-Zhi-Shao-Yao-Zhi-Mu-Tang. ConclusionThe CHMs use was associated with lower risk of stroke for RA patients, suggesting that it could be integrated into conventional therapy to prevent subsequent stroke incident.