Role In Stroke Prevention Research Articles

Chronic loneliness and the risk of incident stroke in middle and late adulthood: a longitudinal cohort study of U.S. older adults

Loneliness has been implicated as a stroke risk factor, yet studies have examined loneliness at only one time point. The association of loneliness changes and risk of incident stroke remains understudied. Our aim was to examine the association of loneliness with incident stroke, particularly the role of loneliness chronicity. This prospective cohort study examined data from the Health and Retirement Study during 2006-2018. For analyses examining baseline loneliness only, we included U.S. adults aged 50 years or older and stroke-free at baseline and excluded individuals missing data on loneliness and those who experienced death at baseline. For analyses examining loneliness changes over two time points, we included those aged 50 years or older at baseline and stroke-free through the exposure measurement period. Individuals missing a loneliness scale measure or those who experienced death during the exposure measurement period were excluded. Loneliness was measured with the 3-item Revised UCLA Loneliness Scale. We constructed loneliness scores (range 3-9), dichotomized loneliness measures (high vs low using a >6 cutoff), and loneliness patterns across two time points (consistently low, remitting, recent onset, consistently high). Cox regression models estimated associations of baseline loneliness (N=12,161) with incident stroke over a 10-12-year period, and loneliness change patterns (N=8936) with incident stroke over a subsequent 6-8-year period, adjusting for demographics, health behaviors and health conditions. Higher loneliness scores at baseline were associated with incident stroke for continuous (hazard ratio [HR]: 1.05, 95% confidence interval [CI]: 1.01-1.08) and dichotomized (HR: 1.25, 95% CI: 1.06-1.47) loneliness measures, and persisted after adjustment for social isolation but not depressive symptoms. Only individuals with a consistently high loneliness pattern over time (vs consistently low) had significantly higher incident stroke risk (HR: 1.56, 95% CI: 1.11-2.18) after adjusting for depressive symptoms and social isolation. Chronic loneliness was associated with higher stroke risk independent of depressive symptoms or social isolation. Addressing loneliness may have an important role in stroke prevention, and repeated assessments of loneliness over time may help identify those particularly at risk. National Institute on Aging (NIA U01AG009740).

Stroke Risk Prediction Based on Machine Learning Algorithms

Stroke is one of the main causes of long-term disability and death around the world. For its significant impact, stroke is also defined as a medical emergency, where immediate treatment is vital to save patients’ lives. For these reasons, an efficient prediction plays an important role in stroke prevention and cure. In this paper, attempting to implement a model predicting stroke efficiently, logistic regression and random forest algorithms are adopted, as well as a stroke dataset. They are trained and make predictions with the preprocessed dataset independently. Multiple evaluation indicators are employed to evaluate the two models’ results. Comparisons between their performances and the reasons for their discrepancies are both introduced, based on which the more suitable one is chosen as the final model. Models’ bias and variance and how they influence the results are discussed as well. In addition, some helpful propositions and approaches to improve the model’s performance will also be introduced.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis.

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

Abstract 15159: Association of Depression and Adherence to Oral Anticoagulants in Patients With Atrial Fibrillation

Introduction: Depression may decrease adherence to cardiovascular medications. Depression has not been well studied in atrial fibrillation (AF). We examined the association of depression with adherence to direct-acting oral anticoagulants (DOACs) in AF, given their crucial role in stroke prevention. We hypothesized that individuals with depression would have decreased adherence to DOACs compared to those without. Methods: We used Optum’s de-identified Clinformatics® Data Mart Database to identify individuals with AF initiating anticoagulation with DOACs between 2013-2019. We identified depression, AF, and covariates using the claims data. We quantified adherence using proportions of days covered, categorized as limited (&lt;80%), adequate (80 to &lt;90%), or optimal (≥90%). We determined the multivariable-adjusted odds of 12-month adherence to DOACs in individuals with depression compared to those without. Covariates included demographics, medical and psychiatric comorbidities, household income, educational attainment, and insurance type. Results: We identified 68,800 individuals with AF who initiated DOACs (age 74.5±8.9, 50.6% female, 29.5% non-White). In those with depression (n=11,059) the odds of adequate adherence was 0.89 (95% CI, 0.85, 0.93) and optimal adherence was 0.87 (95% CI, 0.83, 0.91) compared to individuals without depression ( Figure ). Conclusions: We demonstrated that individuals with depression and comorbid AF were less likely to achieve either adequate or optimal 12-month adherence to DOACs compared to those without depression. Recognizing depression in patients with AF may guide measures to address adherence to oral anticoagulation.

Atherosclerotic Carotid Artery Disease: Where to from the emergency room? University hospital experience.

Stroke is the second leading cause of death worldwide, resulting in 5.5 million deaths in 2016. Vascular interventions, including carotid endarterectomy (CEA) and carotid artery stenting, play a major role in stroke prevention, especially when performed early after onset of symptoms. This study aimed to define the role of vascular surgeons in ischaemic stroke management and hence improve referral patterns by creating an algorithm for the referral process. This could reduce time to intervention and optimise patient benefit from intervention. This retrospective study reviewed symptomatic and asymptomatic patients with atherosclerotic disease of the carotid artery who were referred to the Vascular Surgery Unit of Sultan Qaboos University Hospital, Muscat, Oman, from April 2018 to March 2020 to examine factors influencing recognition of suitable candidates for intervention. Following analysis of the data, algorithms/protocols were created to simplify the referral process of symptomatic and asymptomatic carotid artery disease for surgical intervention. A total of 38 patients with ischaemic stroke were recognised as having carotid artery stenosis and were referred to the vascular surgery service during the study period. Only six met the criteria for CEA, four of which underwent the procedure. Choice of patients for CEA involves multiple steps, with potential for missed opportunities. By involving a multidisciplinary team approach, the recommended protocol aims to lead to early and appropriate referral to a vascular surgeon or an interventional radiologist, resulting in increased and optimised intervention in stroke prevention.

Diet a modifiable risk factor for stroke: linking diet and stroke; an Indian perspective

Stroke is the second leading cause of death and disability worldwide. The incidence of stroke in India has increased to hundred percent in past few decades. It was the Framingham heart study trial in 2001 which has first identified the role of dietary habits for prevention of atherosclerotic cardiovascular disease. Majority of secondary prevention strategies for Ischemic stroke are directed towards pharmacotherapy with antiplatelet and statins, while dietary modifications are not projected. However dietary and lifestyle modification can reduce stroke risk by 60%. Hence Diet and nutrition play an active role in prevention of stroke. This review summarizes the dietary intake, dietary patterns and risk of stroke among Indians and provides clinicians with pragmatic guidance to their management. We searched Pub Med, MEDLINE, for articles about diet and stroke in India published in English till May 2021. Diet plays a major role in pathophysiology of stroke. Modification of dietary pattern is the major non pharmacological treatment for the primary and secondary prevention of stroke. Indian traditional diet should be modified according to dietary pattern followed in each region. As a whole reduction of rice consumption, higher protein consumption and lower fat consumption should be encouraged at macronutrient level, while higher intake of fruits and vegetables are advised at micronutrient level. Dietary guidelines should be customized and tailor made based on the regional customs and annual income in various subsections of the society.

Time Window for Acute Stroke Management: A Cross-Sectional Study Among Community Healthcare Practitioners in Primary Care.

IntroductionTime-to-treatment window is critical for managing acute ischaemic stroke. The community healthcare practitioners (CHPs) who deliver frontline care in the health system play an important role in stroke prevention and treatment.MethodsA multi-stage sampling design was adopted in Guangdong province, China. A total of 997 CHPs who participated in the survey were divided into two groups (the awareness group vs the unawareness group) according to their knowledge on the time window for stroke management. Logistic regression analysis was performed to explore factors associated with the awareness of “time window”.ResultsOverall, less than half (49.1%) of CHPs were aware of the time window for stroke management. The proportion of CHPs who were able to recognise stroke symptoms were higher in the awareness group (42.7%) than that in the unawareness group (38.8%). Most CHPs (82.9%) in the awareness group had the knowledge about the effectiveness of intravenous thrombolysis in treating acute cerebral infarction, whereas this was perceived by only less than half (43.6%) of CHPs in the unawareness group. Factors associated with the knowledge of time window for stroke management included participation in cerebrovascular disease management training (adjusted odds ratio [aOR]=4.203, 95% CI: 1.707–10.348, p=0.002), awareness of the time frame for CT initiation (aOR=5.214, 95% CI: 1.803–15.078, p=0.002) and for urokinase thrombolysis administration (aOR=11.927, 95% CI: 4.393–32.382, p<0.001), accurate perceptions about the target for blood pressure lowering (aOR=4.181, 95% CI: 1.713–10.207, p=0.002) and blood glucose control (aOR=2.446, 95% CI: 1.019–5.869, p=0.045), and the familiarity with prehospital stroke management principles (aOR=3.593, 95% CI: 1.383–9.332, p=0.009).ConclusionThe CHPs need to enhance their ability to address the acute ischaemic stroke onset promptly to provide effective treatment within the beneficial “time window”. This may help improve the stroke chain of survival with better multidisciplinary decision support systems that enable optimal stroke care delivery.

EDUKASI PENINGKATAN PERAN KELOMPOK CERDIK DALAM PENCEGAHAN STROKE DI WILAYAH KERJA PUSKESMAS KEBUN SIKOLOS PADANG PANJANG

In early 2018, the UPTD of Kebun Sikolos Health Center made an innovation by establishing a Smart Group, namely the development of the Serambi Prolanis Group. The management of this group was modified so that the activities did not only focus on medical consultations, home visits, reminders, group activities and monitoring of health status, but were also developed into agents providing information, promotion and health education in the neighborhood. The goal is to encourage participants with stroke to achieve optimal quality of life. This ingenious group consists of 200 people and not all of the elderly here have good behavior in preventing stroke, including smoking and consuming fatty foods. This Smart Group has attended training conducted by community nurses on stroke elderly aggregates to help community groups learn new knowledge and skills related to stroke care and provide encouragement to group members. The purpose of community service is to increase the role of the Smart group in terms of motivation, health promotion and stroke prevention efforts through the provision of comprehensive education. The results of pre and post tests regarding the knowledge of members of the smart group related to their role in stroke prevention were very good. Conclusions and suggestions for good behavior in stroke prevention in the UPTD Working Area of ??Kebun Sikolos Health Center Padang Panjang can be realized through education to increase the role of smart groups about understanding and good application of motivation, communication, acting as role models, prioritizing educational goals for families, neighbors and communities in residential environment and the general public as well as ways to prevent stroke.&#x0D; Keywords: smart group, participation, stroke prevention behavior

Abstract P685: Primary Care Utilization for Primary Prevention Continues to Be Lacking in Patients With Stroke

Introduction: Primary care plays an essential role in stroke prevention. Yet still, for many stroke patients, a relationship with a primary care provider (PCP) is not established until after stroke. Our goal was to determine if lack of PCP and the consequential differences in management affects stroke severity. Methods: Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019 of all stroke subtypes (ischemic stroke, transient ischemic attack, subarachnoid and intracerebral hemorrhages). Non-parametric Mann Whitney t-test and regression analysis was used to identify significant differences in medications, stroke risk factors and stroke severity. Results: A total of 559 patients were included, median age 67 (interquartile range (IQR) 58-76), 49% woman, 32% established care with a PCP, 36% on medications for diabetes mellitus (DM), 42% hyperlipidemia, 66% anti-hypertensives, 39% anti-platelet agents, and 10% anticoagulation. More patients with PCP were taking anti-hypertensive medications (80% versus (vs) 60%, p value &lt; 0.0001), DM medications (56% vs 30%, p value &lt; 0.0001), anti-platelet agents (46% vs 35%, p value = 0.0149), and medications for hyperlipidemia (49% vs 39%, p value = 0.0426). Admission NIHSS was lower in patients with a PCP median 6 (IQR 3-11) vs median 9 (IQR 4 -15), p value= 0.0016, and median hemoglobin A1c was higher in patients with a PCP 8 (IQR 5.7- 9.3) vs patients without a PCP prior to their stroke 6 (IQR 5.4 - 8.5), p value= 0.0002. Admitting systolic blood pressure was similar 155 (137-177) vs 152 (134-171). After correcting for age and gender, regression analysis demonstrated a significant association between whether a patient had PCP and antihypertensive medication use (odds ratio (OR) 2.413, 95% confidence interval 1.511 - 3.914) and hemoglobin A1c (OR 1.122, 95% CI 1.037 - 1.215). Also, patients with a PCP were more likely to have a lower NIHSS on admission (OR 0.9679, 95% CI 0.9423 - 0.9930). Conclusions: These result show that patients not followed by a PCP prior to stroke are less likely to be on medications for primary prevention of stroke, contributing to an increased stroke severity on admission. More research is needed to identify barriers to patients establishing care with PCP.

Chapter 28 - Hemodynamics in acute stroke: Cerebral and cardiac complications

Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.

A Prospective Observational Study on Risk Factors and Prescribing Patterns of Drugs used in Stroke Patients at a Tertiary Care Teaching Hospital.

Objectives: The main aim of the study is to identify the different risk factors, prescribing patterns of medication and rationality of the prescription by observing the management of stroke patients carefully.&#x0D; Methodology: A prospective and observational study was carried out for a period of 6 months in an in-patient department of a tertiary care hospital. Patients above 18 years of age, patients of either sex and patients who previously had stroke were included. Children below 18 years, pregnant women, AIDS patients, patients unable to respond to verbal questions with no caretakers and patients with head injury were excluded.&#x0D; Results: A total of 100 prescriptions were analyzed during the 6 months study period. This was found to be higher in males (79) and females (21). The higher risk with notable occurrence in the age group of 60-79 years (43%). Out of these study populations, (68%) experienced Ischemic stroke and (32%) experienced Hemorrhagic stroke. The major risk factors were Hypertension (62%), alcoholics (41%). Smoking (33%) and Diabetes (24%). Among the 100 prescriptions, Atorvastatin was highly prescribed (96) followed by Pantoprazole (92), Mannitol (64). Out of 100 prescriptions, (67) were rational and (33%) were irrational.&#x0D; Conclusion: The prescribing patterns of drug should be based on specificity and severity of stroke in order to facilitate rational use of drugs providing optimal care. Early management of hypertension and diabetes may reduce risk of stroke. Cessation of smoking and alcohol place a key role in prevention of stroke.&#x0D; Keywords: Ischemic stroke, hemorrhagic stroke, hypertension, diabetes.

Dietary docosahexaenoic acid inhibits neurodegeneration and prevents stroke.

Stroke severely impairs quality of life and has a high mortality rate. On the other hand, dietary docosahexaenoic acid (DHA) prevents neuronal damage. In this review, we describe the effects of dietary DHA on ischemic stroke-associated neuronal damage and its role in stroke prevention. Recent epidemiological studies have been conducted to analyze stroke prevention through DHA intake. The effects of dietary intake and supply of DHA to neuronal cells, DHA-mediated inhibition of neuronal damage, and its mechanism, including the effects of the DHA metabolite, neuroprotectin D1 (NPD1), were investigated. These studies revealed that DHA intake was associated with a reduced risk of stroke. Moreover, studies have shown that DHA intake may reduce stroke mortality rates. DHA, which is abundant in fish oil, passes through the blood-brain barrier to accumulate as a constituent of phospholipids in the cell membranes of neuronal cells and astrocytes. Astrocytes supply DHA to neuronal cells, and neuronal DHA, in turn, activates Akt and Raf-1 to prevent neuronal death or damage. Therefore, DHA indirectly prevents neuronal damage. Furthermore, NDP1 blocks neuronal apoptosis. DHA, together with NPD1, may block neuronal damage and prevent stroke. The inhibitory effect on neuronal damage is achieved through the antioxidant (via inducing the Nrf2/HO-1 system) and anti-inflammatory effects (via promoting JNK/AP-1 signaling) of DHA.

Epidemiology and Primary Prevention of Stroke.

This article provides an update on the epidemiology and prevention of a first stroke. Risk factor modification plays a large role in stroke prevention. Strategies for early intervention, particularly for hypertension, are critical for reducing stroke morbidity and mortality. Because of the new criteria for hypertension, more people are now classified as hypertensive and can benefit from lifestyle or medical management. Direct oral anticoagulants have made it easier to safely treat patients with atrial fibrillation and are now considered first-line therapy for patients with an additional stroke risk factor. Primary prevention of stroke is essential for maintaining brain health throughout the life span. Adherence to a healthy lifestyle and routine screening for stroke risk factors can promote healthy, stroke-free aging.

Barriers and Facilitators to Chronic Red Cell Transfusion Therapy for Children with Sickle Cell Anemia: Results from the Displace Consortium

Introduction: Chronic red cell transfusion therapy (CRCT) is one of the only disease-modifying therapies for individuals with sickle cell anemia (SCA). CRCT plays a particularly critical role in stroke prevention for children with SCA who are at high risk (primary prevention) or who have had a previous stroke (secondary prevention). CRCT is also used to prevent other non-neurologic severe complications from SCA, such as recurrent splenic sequestration or severe acute chest syndrome. Only a few previous studies have focused on patient and provider experiences related to CRCT. This previous work has predominantly focused on patient/caregiver perceptions of children's quality of life while receiving CRCT and provider decision-making around CRCT for SCA. The present study sought to build on this previous work by examining barriers and facilitators to CRCT for stroke prevention as part of the aims of the Dissemination and Implementation Looking at the Care Environment (DISPLACE) study. DISPLACE is a multi-site study funded to evaluate and improve implementation of stroke prevention practices for SCA. The goal of this particular aim was to inform optimal strategies to enhance CRCT initiation for stroke prevention in SCA. Methods: A qualitative descriptive approach was used to obtain provider and patient/caregiver perspectives through key informant interviews with open-ended questions. Purposive sampling was used to identify patient/caregiver participants and purposive and snowball sampling were used to identify provider participants with the goal of enrolling participants until data saturation was reached. Interviews were digitally audio recorded and transcribed for analysis. Data were analyzed using inductive and deductive approaches. Deductive analysis followed the directed content analysis approach with the Multilevel Ecological Model of Health as an initial coding framework. Themes were developed around the barriers and facilitators to CRCT from an ecological perspective. Results: Fifty-two interviews were completed across patients/caregivers and providers (27 patient/caregivers and 25 providers) in order to reach data saturation. For patient/caregivers, 26 caregivers of children and adolescents with SCA (mean age = 39; 21 mothers, 4 fathers, and 1 aunt) and one young adult (age 18, female) completed interviews. For providers, 19 physicians, 2 nurse practitioners, 1 physician assistant, and 3 ancillary providers completed interviews (mean age = 50; 14 female; mean years of practice in SCA = 18.8). Patient/caregiver and provider themes were consistent with the multi-ecological framework and reflected barriers and facilitators at the patient, provider, organizational, and social-environmental/policy levels (Figure 1). Predominant (or high-frequency) themes with definitions and illustrative quotes are presented in Table 1. Predominant barriers reported by patients/caregivers and providers included: logistical challenges (patient level), obtaining and maintaining venous access (patient level), and alloantibodies/alloimmunization and transfusion reactions (patient level). A predominant barrier reported by providers was iron overload and adherence to chelation therapy (patient level). Predominant facilitators reported by patient/caregivers and providers included: nursing and non-nursing staff support (provider level), positive child/family experience (organizational level), and logistical help and social resources (social-environmental and policy level). Predominant facilitators reported by providers included transfusion-specific resources (organizational level) and proximity to a blood bank and access to blood (organizational level). Conclusions: Patient/caregivers and providers reported a range of barriers and facilitators to CRCT, though most occurred at the patient and organizational levels. Many of the barriers and facilitators also involved interactions across ecological levels. Results suggest interventions should address predominant and remediable barriers (e.g., logistical challenges and obtaining and maintaining venous access) and incorporate predominant facilitators (e.g., nursing and non-nursing staff support and positive child/family experience). Findings from this study may be used to guide interventions for improving CRCT initiation among children with SCA. Disclosures Adams: GBT: Consultancy, Other: consultancy to companies GBT and Blueburd Bio; Bluebird: Consultancy.

Antithrombotic treatment is associated with intraplaque haemorrhage in the atherosclerotic carotid artery: a cross-sectional analysis of The Rotterdam Study.

AimsAntithrombotic treatment plays a key role in stroke prevention, but their direct effects on the composition of carotid artery atherosclerotic plaques are unknown. To investigate the association of antithrombotic treatment with carotid artery plaque composition, with a specific focus on an intraplaque haemorrhage (IPH).Methods and resultsFrom the population-based Rotterdam Study, 1740 participants with carotid atherosclerosis on ultrasound (mean age 72.9 years, 46.0 women) underwent magnetic resonance imaging of the carotid arteries to assess plaque composition. Information on the use of oral anticoagulants [vitamin K antagonists (VKA)] and antiplatelet agents (salicylates), including duration of use and dosage, was obtained from pharmacy records for all participants. We used logistic regression models to assess the association between the use of anticoagulants and antiplatelet agents, and the different plaque components adjusting for confounders. Current and past use of VKA [adjusted odds ratio (OR): 1.88, 95% confidence interval (CI): 0.74–4.75 and OR 1.89, 95% CI: 0.91–3.93] and antiplatelet agents (OR: 1.22, 95% CI: 0.91–1.62), and (OR: 1.23, 95% CI: 0.86–1.75) showed positive trend with a higher presence of IPH. Also, a longer duration of use was associated with a higher frequency of IPH (OR: 3.15, 95% CI: 1.23–8.05) for the use of VKA, and longer duration of the use for antiplatelet agents showed a positive trend (OR: 1.21, 95% CI: 0.88–1.67). We also found that higher levels of international normalized ratio above 2.97 for VKA (OR: 1.48, 95% CI: 1.03–2.15) and higher daily defined dosage than 1.0 for antiplatelet agents (OR: 1.50, 95% CI: 1.21–1.87) were related to a higher frequency of IPH. We found no association with lipid core or calcification.ConclusionsThe use of antithrombotic treatment relates to a higher frequency of IPH in carotid atherosclerotic plaques.

New oral anticoagulants: their role in stroke prevention in high-risk patients with atrial fibrillation.

Based on efficacy, safety, and ease of use, novel oral anticoagulants will likely replace VKAs for many if not most patients with atrial fibrillation. Novel anticoagulants have a lower rate of intracranial hemorrhage compared with vitamin K antagonists. The incidence of other life-threatening bleeds is similar if not lower. Dose adjustments need to be made based on renal function and advanced age. There is at present a need for an antidote for these new drugs.

An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug–drug and drug–food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy.

Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis

BackgroundCarotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate. MethodsThe National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death. ResultsDuring an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate (P < .001). ConclusionsA high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.

Atrieflimmer og hjerneslag

More than 70,000 Norwegians have atrial fibrillation, which is a major risk factor for ischemic stroke. A large proportion of ischemic strokes caused by atrial fibrillation could be prevented if patients receive optimal prophylactic treatment. This article describes the risk for ischemic stroke in patients with atrial fibrillation, and discusses who should receive prophylactic treatment and which therapy provides the best prevention. The article is based on recently published European, American and Canadian guidelines, a search in PubMed and the authors' own clinical experience. The new risk score CHA2DS2-VASc is better than the CHADS2 score for identifying patients with atrial fibrillation who have a truly low risk of ischemic stroke and are not in need of antithrombotic treatment. Oral anticoagulation therapy is recommended for patients with two or more risk factors for thromboembolism in addition to atrial fibrillation (CHA2DS2-VASc ≥ 2). Patients with atrial fibrillation and a single additional risk factor (CHA2DS2-VASc =1) an individual assessment should be made as to who should receive oral anticoagulants, and for patients with CHA2DS2-VASc = 0 antithrombotic treatment is not recommended. New oral anticoagulants are at least as effective as warfarin for preventing ischemic stroke in patients with nonvalvular atrial fibrillation, they carry a lower risk of cerebral haemorrhage, especially intracranial haemorrhage and are more practical in use. Platelet inhibitors have a minimal role in stroke prevention in patients with atrial fibrillation. Risks stratifying patients using the CHA2DS2-VASc score is a better method for assessing which patients with atrial fibrillation who should receive oral anticoagulation. The introduction of new oral anticoagulants will simplify preventive treatment and hopefully lead to a more efficient anticoagulation treatment in a larger number of patients with atrial fibrillation.

The Challenge of Antiplatelet Therapy in Patients with Atrial Fibrillation and Heart Failure

Antiplatelet therapy is the cornerstone of secondary prevention in cardiovascular disease. This review focuses on the role of antiplatelet therapy in atrial fibrillation (AF) and heart failure (HF). Aspirin has a limited role in stroke prevention among most patients with AF, being of limited efficacy and not any safer than warfarin, especially in the elderly. For HF patients with AF, cardioembolism is a major cause of stroke, and antiplatelet alone would be insufficient thromboprophylaxis. Aspirin plus clopidogrel rather than aspirin alone is preferred for those AF patients who have refused any form of oral anticoagulation. For AF patients undergoing percutaneous coronary intervention, triple antithrombotic therapy (aspirin, clopidogrel, and warfarin) is recommended for the initial period (1-6months) based on the stent type, followed by vitamin K antagonists (VKA) and clopidogrel or, alternatively VKA and aspirin for up to 12months. In AF patients with stable vascular disease, VKA monotherapy would suffice.