Secondary Prevention Of Cerebrovascular Disease Research Articles

Impact of Concurrent Ischaemic Stroke on Unfavourable Outcomes in Men and Women with Dilated Cardiomyopathy.

Growing evidence suggests that concurrent ischaemic stroke (IS) exacerbates the prognosis of patients with dilated cardiomyopathy (DCM) and that this effect may be further influenced by sex. However, the exact effect of sex remains unclear. This study aimed to explore the effects of the relevant risk factors on the prognosis of patients with DCM and concurrent IS. Considering the sex differences in DCM, this study further investigated the impact of concurrent IS on the prognosis of men and women with DCM. A total of 632 patients with DCM enrolled between 2016 and 2021 were included in this study. Clinical data were obtained from medical records, and all participants were followed up in the outpatient clinic or by telephone for at least 1 year. A Cox proportional hazards model and Kaplan-Meier curves were used to evaluate the effects of concurrent IS on the prognosis of patients with DCM. Patients with DCM complicated with IS (DCM-IS) had significantly lower cumulative survival rates than patients with DCM without IS (non-IS) (74.6% vs. 84.2%, 2 = 6.85, p = 0.009). Additionally, IS was associated with greater risks of death and heart transplantation (HTx) in men (75.8% vs. 85.1%, 2 = 5.02, p = 0.025), but not in women (71.0% vs. 81.5%, 2 = 1.91, p = 0.167). This large-scale multicentre prospective cohort study demonstrated a poorer prognosis in patients with concurrent DCM and IS, particularly among men. Patients with DCM should not be overlooked in IS screening, emphasis should be placed on the occurrence of IS in patients with DCM. Early and proactive secondary prevention of cerebrovascular diseases might improve the prognosis of DCM patients. More intervention studies focusing on men with DCM complicated with IS should be prioritised.

Cholesterol Paradox in Older People with Type 2 Diabetes Mellitus Regardless of Lipid-Lowering Drug Use: A Cross-Sectional Cohort Study.

Lipid-lowering drugs (LLDs) have protective effects against coronary artery disease (CAD) and cerebrovascular disease (CVD); however, a paradoxical association with cholesterol has been identified in several diseases, such as diabetes, dementia, and atrial fibrillation. We aimed to analyze the association between LLDs and cholesterol levels in older adults with type 2 diabetes mellitus (T2DM). This cross-sectional study enrolled consecutive patients aged ≥50 years from three centers in Taiwan. A multiple logistic regression model was used, and odds ratios (ORs) for different levels of total cholesterol (TC) or low-density-lipoprotein cholesterol (LDL-C) compared with the highest level were adjusted for age, triglyceride level, sex, comorbidities, and medications. Among the 3688 participants, 572 with and 676 without T2DM used LLDs. After adjusting for age and sex, the non-T2DM group demonstrated better medical conditions, cognition, and daily function than the T2DM group, regardless of LLD use. Compared to the highest TC level (≥240 mg/dL), ORs were significantly increased as TC levels decreased. A similar pattern of T2DM prevalence was observed in LDL-C levels. Older people with T2DM demonstrated low cognitive and daily functions. Significantly reduced TC and LDL levels were associated with a higher T2DM prevalence in older adults regardless of LLD use. T2DM was associated with impaired cognitive and daily functioning. A higher prevalence of T2DM in older people with low cholesterol levels raises doubt surrounding cognition and daily function being jeopardized when the "lower is better" strategy is applied for the secondary prevention of CAD or CVD.

Risk factors and adherence to treatment of patients with cerebrovascular diseases

To assess the representation of risk factors and treatment adherence in patients with cerebrovascular diseases. A single-stage cross-sectional non-comparable study was conducted, which included 492 patients, of whom 133 had an ischemic stroke/transient ischemic attack (main group, MG), 344 had chronic cerebrovascular pathology (comparison group, CG). The representation of risk factors, the state of cognitive functions, the severity of anxiety and depression were evaluated. MG respondents visit specialized specialists more often than CG (p<0.001), are more committed to taking antiplatelet agents (p<0.003), statins (p<0.005), antihypertensive drugs (p<0.005). Regular intake of antithrombotic drugs was associated with the history of ischemic stroke (r=0.483; p<0.01), type 2 diabetes (r=0.637; p<0.011), atrial fibrillation (r=0.481; p<0.001), living in a family (r=0.493; p<0.03). An inverse correlation was established between the systematic intake of antiplatelet drugs and the age of the respondents (r=-0.637; p<0.002), cognitive impairment (r=-0.433; p<0.05), the history of the gastrointestinal tract diseases (gastric ulcer and duodenal ulcer) (r=-0.563; p<0.001). Irregular medication intake was observed in patients aged over 60 years compared with younger (17.3% and 6.4%, respectively, p=0.001), patients living in a family compared with single (85.6% and 65.1%, p=0.032). The history of ischemic stroke or myocardial infarction is associated with increased adherence to regular medication. The study of risk factors and the assessment of treatment adherence can ensure the formation of an effective strategy for primary and secondary prevention of cerebrovascular diseases.

Ilaprazole and Clopidogrel Resistance in Acute Stroke Patients.

Clopidogrel, an antiplatelet agent used for secondary prevention of cerebrovascular diseases, is often taken with proton pump inhibitors (PPIs). Generally, the combined use of clopidogrel and PPIs causes adverse drug–drug interactions. VerifyNow is a quick and convenient method to confirm clopidogrel resistance (CR), which compromises adequate antithrombotic effects. We aimed to confirm CR, identify its factors, and determine the influence of the combination of ilaprazole and clopidogrel on clopidogrel using VerifyNow. In this retrospective study, we examined patients who were receiving clopidogrel after three months, starting within one week from the onset of cerebral infarction symptoms. Clinical records, imaging records, and diagnostic laboratory results, including P2Y12 reaction units (PRU), were compared and analyzed to check for CR. Additionally, the groups treated with either both ilaprazole and clopidogrel or with medications other than ilaprazole were comparatively analyzed. CR was defined as a PRU ≥240 after clopidogrel for three months. Among factors influencing CR by affecting clopidogrel metabolism, positive statistical correlations with age and alcohol consumption were confirmed. The diagnostic tests revealed a lower glomerular filtration rate and platelet count of the CR-positive group. This finding proved that the combination therapy of ilaprazole and clopidogrel is safe, as it does not interfere with the metabolism of clopidogrel.

Associations between Intensive Lipid-lowering Therapy and Outcomes of Intracerebral Hemorrhage

Background: The intensive lipid-lowering therapy (ILLT), targeting an low-density lipoprotein cholesterol (LDL-C) &lt; 1.80 mmol/L, was a crucial strategy for the secondary prevention of cerebrovascular diseases. But the associations between ILLT and the outcomes after intracerebral hemorrhage (ICH) were unclear. Materials and Methods: Data of the consecutive patients with acute ICH and past medical histories of ischemic stroke from 2017 to 2019 at an academic stroke center in China were analyzed. The study patients were classified according to their baseline LDL-C levels: &lt; 1.80 mmol/Lvs. ≥ 1.80 mmol/L. The outcomes of ICH were compared between the two groups. Multivariate linear mixed effect model with repeated measures adjusting for ICH scores were used to determine the associations between LDL-C levels and the change in NIHSS scores; baseline ICH scores were adjusted in the multi-variable models Results: A total of 197 patients were included in the study, 31 of them had LDL-C &lt; 1.80 mmol/L and 166 had LDL-C ≥ 1.80 mmol/L. We did not test any significant differences regarding the demographic characteristics or vascular risk factors. Medians of the baseline National Institutes of Health Stroke Scale (NIHSS) scores (8 vs. 9, P = 0.79) and ICH scores (1 vs.1, P = 0.26) were similar. But the patients with LDL-C &lt; 1.80 mmol/L had higher risks of secondary intraventricular hemorrhage (13% vs. 4%, P = 0.03). Outcomes of the hemorrhagic stroke at discharge were similar, except the patients with LDL-C ≥ 1.80 mmol/L had significant improvements in their NIHSS scores at discharge (estimated change in means: -2.4, 95% CI: [-4.3, -0.5]), while patients with LDL-C &lt; 1.80 mmol/L did not (estimated change in means: -1.4, 95% CI: [-5.9, 3.0]). Conclusion: ILLT achieved LDL-C &lt; 1.80 mmol/L was associated with limited improvements in the neurological deficits in the patients with ICH.

Use of the Cardiovascular Polypill in Secondary Prevention of Cerebrovascular Disease: A Real-Life Tertiary Hospital Cohort Study of 104 Patients

Background: The use of the cardiovascular polypill, a fixed-dose combination treatment, is conceived to improve adherence. However, randomized controlled trials (RCTs) may overestimate it. Studies focusing on cerebrovascular disease and real-life efficacy compared with conventional treatment are lacking. Methods: This is a retrospective, hospital-based cohort study of acute ischaemic stroke patients who were prescribed a polypill (aspirin 100 mg, atorvastatin 20/40 mg, ramipril 2.5/5/10 mg) versus conventional treatment (aspirin 100 mg and other blood pressure/lipid-lowering agents) in secondary prevention (2017–2018). Clinical records were reviewed 90 days after discharge for stroke recurrence, vascular risk factor control, and safety. Adherence was assessed using the adapted Morisky-Green scale. Results: A total of 104 patients were included (61% male; mean age 69.7 ± 13.9 years); 54 were treated with the polypill and 50 with conventional treatment. No baseline differences in clinical or demographic variables were detected. No recurrences were registered in the polypill group, compared to 1 recurrence in the conventional treatment group. A significant reduction of systolic blood pressure (SBP) was achieved in the polypill group (12.1 mm Hg) compared to the conventional treatment group (6.8 mm Hg) (p = 0.002). No significant differences were detected regarding the goal of LDL cholesterol ≤70 mg/dL (41 vs. 44%). The adverse events were mild and their frequency was similar in the two groups (9 vs. 2%, ns). Adherence was similarly good in the two groups (93 vs. 88%, ns). Polypill group adherence was similar to that reported in a previous meta-analysis of RCTs (93 vs. 84%, ns). Conclusion: In our experience, the cardiovascular polypill achieved a higher reduction in SBP levels and was well tolerated. Adherence was similar to that found in the previous literature, which is remarkable given the real-life setting of our study.

Expanding the possibilities of antithrombotic therapy of cerebrovascular pathology

The paper provides an overview of the current state of the problem of antithrombotic therapy in angioneurology. Given the importance and prevalence of cerebral atherosclerosis as one of the leading etiological factors of acute and chronic cerebrovascular disorders (CCD), the paper focuses mainly on antiplatelet therapy. The most recent recommendations for the use of acetylsalicylic acid and clopidogrel, the main antiplatelet drugs, are highlighted. The clinical failure of primary or secondary prevention of cerebrovascular diseases, one of the reasons for which is resistance to the therapy, is considered separately. The authors discuss the causes of aspirin resistance and ways to overcome it, one of which may be a switch to another drug. The well-known medication dipyridamole is proposed as a possible alternative and/or addition to the treatment regimen. The most modern ideas about the mechanisms of its action are described, the pleiotropy of its effects is emphasized. The results of own studies on assessment of the effectiveness and safety of dipyridamole (curantil) in patients with various forms of CCD are presented. The results of the CCD pilot project to study the antiplatelet profile of dipyridamole in patients with such a cause of ischemic NMC as Ph-negative myeloproliferative diseases are discussed separately. It is noted that when prescribing both dipyridamole and acetylsalicylic acid preparations, comparable platelet aggregation levels are determined. In conclusion, the need to follow the paradigm of personalized therapy is emphasized, in which individually selected therapy is prescribed (including) taking into account resistance to a particular drug.

Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

IntroductionThere is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered. MethodsA group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review. ResultsThese recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments. ConclusionsThis document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.

Preeclampsia and Cerebrovascular Disease.

Preeclampsia and Cerebrovascular Disease.

Cost-effectiveness of home blood pressure telemonitoring and case management in the secondary prevention of cerebrovascular disease in Canada.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost-effectiveness assessments are mixed. We examined the incremental cost-effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost-utility analysis examining community-residing, high-risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality-adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention-associated BP lowering, resource use, and costs were obtained from Canadian published literature.Reduction in systolic BP of 9.7mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per-patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost-effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2-3 times base case cost, incremental cost-effectiveness was $1200-$4700 per quality-adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

Chronic cerebral circulatory disorders: possibilities of enhancing the efficiency of therapy

Chronic cerebral circulatory disorders (CCCDs) are a group of syndromes manifested by cognitive, emotional disturbances and less commonly motor and sensory neurological symptoms, which is heterogeneous in the mechanisms of development. The prevention of CCCDs involves the control of blood pressure and glycemia and the use of antiplatelet and other drugs; however, the efficiency of these measures for an already formed defect is low. The paper emphasizes the need for careful consideration of a patient's status at the beginning of treatment measures. Combined treatment, including secondary prevention of cerebrovascular disease, drugs that improve cerebral blood circulation and metabolism, and non-drug techniques, can be expected to have a more significant clinical effect. The possibilities of drug therapy, including the use of vinpotropile, in patients with CCCD, are considered.

A Prospective View of Therapeutic Strategy of Atherosclerosis in Cardiovascular Diseases

Submit Manuscript | http://medcraveonline.com and acute outbreak of stroke at the first time in China with imagine technology (CT and TCD) as early as in 1995 [1]. Then the team accessed and compared the four stroke evaluation scales that generally used in Europe; USA; Japan and China with acute stroke inpatients; which was the first time to bring the bridge of clinical research about stroke between China and the rest of world [2]. Knowing the significant of rehabilitation in outcome of stroke; Beijing Tiantan Hospital built stroke units setting for inpatients to satisfy the world standard of clinical research of stroke; and performed the therapeutic effects and prospective study of intervention and antiplatelet agents (Clopidogrel combining with Aspilin) application to atherosclerosis and stroke patients [3]; which provided the fundamental data for the guideline of primary and secondary prevention of cerebrovascular diseases in China. According to their achievement; an innovative system; Chinese Ischemic Stroke Subclassification (CISS) was created and spreadingly employed within hundreds hospitals offering standard and accurate classification for clinical information of stroke in China [4]. ACURE Biotechnology; INC.; backed with extensive basic and translational research in neuroscience; lipids metabolism; cell microenvironment; angiogenesis and infectious diseases; holds 5 patents in therapeutic and preventive strategies for vascular diseases. A novel gene with same N-terminal motif to G-couple proteins was originally discovered by this company’s founder as early as in 2001; had been demonstrated that is play important role in immune and brain associating with lipid rafts [5]. The founder later discovered that the intracellular accumulation of ceramide; the original backbone for most lipids; causes mitochondria dysfunction and leads to severe defect of development of cardiovascular in a Ceramide Transfer Protein (CERT) mutant mouse model [6]. Recently the company established an animal model studying the association between secretion of cytokines (IL17; VEGF) in infectious diseases and vascularization [7]. Thereby a hypothesize that mitochondria dysfunction of smooth muscle cells in vessels wall caused by hypertension; diabetes; high fat or glucose diets; viruses and bacteria infection; and diseases lowering blood oxygen; aging and degeneration diseases; produces abnormal lipids metabolites; which cause the local acute; then process to chronic inflammation; cell death and calcification--the pathological changes of atherosclerosis. Here address to this hypothesis; we summarize a comprehensive therapeutic strategy in atherosclerosis for our collaboration: Evaluating; monitoring and controlling the risk factors of stroke in a community system; Establishment of epigenetic gene markers to predict high-risk population of stroke for preventive medicine; Developing and discovering innovative immunotherapy and drugs to remove or stabilize atherosclerosis lesions; discovering new drugs to improve the formation of collateral circulation in brain after stroke; Combination of acute care; rehabilitation and traditional Chinese medicine to improve the outcome of stroke patients.

Cerebrovascular diseases: perspectives of pathogenetic metabolic haemangiocorrective treatment

Metabolic syndrome is a serious risk factor for acute and chronic cerebrovascular disease, which are a leading cause of disabling conditions. The association of proatherogenic effects of the main components of metabolic syndrome--hyperinsulinemia, arterial hypertension, dyslipidemia and obesity--leads to prominent haemorheological and hemostasis changes, which in turn play a pivotal role in the initiation, course and outcome of cerebrovascular pathology. Metabolic syndrome also influences the efficacy of the main pathogenetic therapy of cerebrovascular diseases--antithrombotic therapy. Thus, primary and secondary prevention of cerebrovascular disease in patients with metabolic syndrome should include haemangiocorrective, antithrombotic, antioxidant and endothelium-protective treatment, as well as therapy of the main components of metabolic syndrome.

Comorbidity polymorphisms and their role in the pathogenesis of cerebrovascular diseases

Background. Hyperhomocysteinemia (HH) is considered a risk factor for generalized atherosclerosis, coronary artery disease, ischemic cerebrovascular events. Objective. To improve diagnostics and primary and secondary prevention of cerebrovascular diseases based on the complex analysis of physical examination, blood tests, instrumental examination in patients with and without HH. Design and methods. Altogether we examined 242 patients. The main inclusion criteria was the presence of chronic cerebrovascular diseases with or without HH of various severity. All subjects underwent physical examination and neurovizualizing tests (magnetic resonance imaging and/or computer scan of the brain). Total homocystein level was assessed by the highperformance liquid chromatography (Agilent 1100) with the photometry detection. Results. Cognitive decline, pyramidal insufficiency (central hemiplegia, cerebellar ataxia), and radicular syndrome were the predominant neurological findings. Conclusion. The result of this study is to expand the range of diagnostic methods and the ability to perform the assessment of the severity of neurological decline taking into account the novel risk factors (such as homocysteine).

Editorial (Thematic Issue: Psychogeriatrics: An Interdisciplinary Approach)

In the past four decades there have been numerous advances in various branches of science in general and medicine in particular that had led to increasing elderly population. Depression, cognitive impairment and dementia are among the most important mental health problems in elderly people. Both conditions have severe consequences for the patients, including diminished quality of life, functional decline, increased use of services, and high mortality. Furthermore, these diseases impact health of caregivers. The World Health Organization considers the care of these pathologies a risk factor for the development of mental disorders and burden. The aim of this thematic issue is to describe different pathologies present in elderly patients and develop these topics with an interdisciplinary approach. This thematic issue focuses on different aspects of psychogeriatrics such as onset age and clinical heterogeneity of dementias. Frontotemporal dementia (FTD) is the main differential diagnosis with early stages of Alzheimer’s disease (AD). Usually, differential diagnosis between a first depressive episode and the beginning of an early degenerative dementia with mood disorders, either AD or FTD, can be difficult. This topic is addressed in the research article of Serrano and colleagues [1], were they conclude that onset age of cognitive and/or behavioral impairment may be one of the variables influencing the clinical heterogeneity of dementias. Many of the young-onset dementias may be potentially reversible so its early identification and pathophysiology understand increase pharmacological intervention opportunities of halting the cascade of events that lead inexorably to dementia. Moreover, cognitive impairment underpins some of the clinical spectrum of the cerebrovascular disease (CVD), as well as contributes to the patient´s impaired social and behavioral functioning, and the higher mortality. Despite a general emphasis in the international literature on the primary and secondary prevention of CVD to avoid vascular dementia or their combination with Alzheimer’s disease, the controversy concerning their diagnostic criteria and optimal treatment is still open. Given its growing burden, the prevention and treatment of CVD and the spectrum of VCI are critical priorities for clinical care and research. Russo and Allegri [2] performed a selective review about the current status of vascular dementia, mild cognitive impairment due to CVD, and mixed dementia, with special emphasis on available evidence of pharmacological strategies for treatment and prevention from controlled clinical trials. Late life depression is a prevalent disorder that affects elderly population and it is frequently associated to cognitive impairment. This disease is sub diagnosed due to great variability in the sample involved, the definition of depression, the methodology used, and the experience of the evaluator. Dillon, Rodriguez and Taragano, in their review [3], analyze the different subtypes of late life depression, the diagnostic methods that can be performed and the pharmacological treatment of this disease. Elderly patients who suffer degenerative diseases generally need caregiving. Considering that the task of caregiving, this is generally carried out by a family member who becomes an easy target for diseases, especially for being subjected to a stressing process. Tartaglini and colleagues [4] studied whether the older caregivers’ health suffers affections if compared with the health conditions of those who do not take care of family members. Environmental complexity states that those individuals involved in activities that require greater cognitive demands keep their cognitive abilities undamaged despite the passing of time. Feldberg, Stefani and Allegri [5] will demonstrate how environmental complexity and the importance of engaging in recreational activities influence individuals’ lives and their cognitive healthy aging. Finally, in relation to pharmacological treatment in dementia, in the last decade, various medications have been used for the treatment of cognitive symptoms in Dementia. Many of them have few scientific evidence of their effectiveness. Pérez Leguizamón and colleagues [6] review and update the current status of the pharmacological treatment of cognitive symptoms in Alzheimer´s Disease, one of the most prevalent and disabling diseases in the elderly.

Vascular Cognitive Disorder: A Diagnostic and Pharmacological Treatment Updating

Cognitive impairment underpins some of the clinical spectrum of the cerebrovascular disease (CVD), as well as contributes to the patient´s impaired social and behavioral functioning, and the higher mortality. When cognitive function is affected by CVD, we name it as vascular cognitive impairment (VCI). The cognitive impairment may be mild, or may be severe enough to warrant a diagnosis of dementia. Pure vascular dementia is not common. Because of that the concept of mixed dementia has been included in the clinical diagnosis of VCI. Despite a general emphasis in the international literature on the primary and secondary prevention of CVD to avoid vascular dementia or their combination with Alzheimer’s disease, the controversy concerning their diagnostic criteria and optimal treatment is still open. Given its growing burden, the prevention and treatment of CVD and the spectrum of VCI are critical priorities for clinical care and research. We performed a selective review about the current status of vascular dementia, mild cognitive impairment due to CVD, and mixed dementia, with special emphasis on available evidence of pharmacological strategies for treatment and prevention from controlled clinical trials. Keywords: Alzheimer's disease, cerebrovascular disease, post-stroke dementia, vascular cognitive impairment, vascular dementia, vascular risk factors.

Abstract T P344: Clopidogrel Resistance in Stroke Patients (The CRISP Trial)

Background: Clopidogrel is a thienopyridine with ADP antagonising effects that is widely used in the secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). Despite this some patients will go on to have recurrent strokes or TIAs. Cardiology trials have identified patients with clopidogrel resistance, defined as a vasodilator-stimulated phosphoprotein (VASP) index of &gt;50% after at least 7 days of clopidogrel treatment. This was associated with recurrent cardiac events. The VASP-index measures phosphorylation of VASP in the resting state and activated states using flow cytometry techniques. As phosphorylation of VASP is dependent upon activation of the platelet P2Y12 receptor that is targeted by clopidogrel the difference in phosphorylation between the two states provides an indirect measure of platelet inhibition. Previous trials have shown a prevalence of clopidogrel resistance in stroke patients of between 8 and 18%, but no study to date has shown whether this is associated with significantly more recurrent cerebrovascular events. We are testing the hypothesis that amongst patients treated with clopidogrel for secondary prevention of cerebrovascular disease, those with resistance are more likely to have recurrent Strokes or TIAs. Should this hypothesis be confirmed, then further research would be needed to identify treatment strategies that may minimise this risk. Design A prospective cohort study recruiting 120 patients from the acute stroke unit at the Royal Liverpool hospital with a diagnosis of stroke or TIA that will be commenced on clopidogrel therapy and expected to continue it for at least one year. We will compare outcomes between those found to be 'clopidogrel responders' and 'clopidogrel resistant'. A sample size of 120 patients was chosen based on the concept of 'reproducibility probability', taking into account the number of patients needed for similar studies in cardiology patients, the prevalence of 'clopidogrel resistance' amongst stroke patients and the potential for patients to later be excluded. Outcome Recurrent cerebrovascular event within 6 months of entering trial. Trial Status Recruitment ongoing.

Assessment of quality of neurosurgical care rendering in secondary prevention of cerebrovascular diseases in Ukraine

Introduction. Effective measures at cerebrovascular disease (CVD) are primary and secondary measures for prevention of brain blood circulation disorders that are used within global (WHO) and national programs.Materials and methods. Results of continuous research of treatment work in Ukrainian neurosurgical units in 2001–2010 years, data of WHO, indicators of neurosurgical and neurologic services in Ukraine and Russian Federation were analyzed.Results and their discussion. In 2010 twice more patients with CVD have been treated than in 2001 (respectively 4837 and 8923). For this period surgical activity grew in 1.4 times (from 33.8 to 47.2%), the number of operations increased in 2.7 times — from 1637 — in 2001 to 4215 — in 2010, the postoperative lethality decreased from 17.2 to 12.3%.Conclusions. Specialization of vascular units and centers — is one of the major factors, influencing on improvement of secondary prevention at patients after vascular attack. Level of providing of CVD secondary neurosurgical prevention is highest in Kiev, sufficient — in Dnepropetrovsk and Kharkov regions and nonsufficient — in other regions of the country.

Risk Factors of Stroke in Pakistan: A Dedicated Stroke Clinic Experience

Secondary prevention of cerebrovascular disease through dedicated stroke clinics has been shown to decrease recurrent vascular events in patients. However, there is limited literature describing such stroke clinic experiences from low and middle income countries. This study describes patient characteristics and observations made at the first systematized stroke clinic in Pakistan. A retrospective audit of medical records of all patients presenting between September 2006 and August 2008 with a cerebrovascular event was conducted. Information about clinical presentation, modifiable risk factors and laboratory and radiological investigations was collected. Burden of disability was assessed using Modified Rankin score. Data was entered and analyzed using SPSS 14.0. 159 patients with a mean age of 57.0 +/- 13.9 years were included in this study and 34.6% of all patients were women. 108 patients were diagnosed with ischemic stroke (67.9%) while 34 patients presented with hemorrhagic stroke (21.4%) and 17 patients presented with transient ischemic attacks (10.7%). Hypertension was the most common modifiable risk factor seen in 78.0%, followed by diabetes in 40.3% and dyslipidemia in 31.5%. At presentation to clinic, only 26.0% patients with dyslipidemia and 64.5% patients with hypertension were on appropriate medications. A high prevalence of modifiable risk factors such as hypertension in stroke patients was observed and it presents an opportunity for conventional interventions in Pakistan. Systematized clinics for stroke and an algorithmic approach in primary care towards stroke may improve the implementation of evidence based secondary prevention strategies in developing countries.

Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study.

We examined patterns in medication use for secondary prevention of cerebrovascular disease in older British men from 1999 to 2005, and investigated socio-demographic and disease-related influences on medication use. Percentage use of antiplatelet drugs, blood pressure-lowering drugs and statins use was calculated in men, aged 65-87 years in 2005, who had been diagnosed with stroke or transient ischaemic attack (TIA) from a population-based cohort based in one general practice in each of 24 British towns. In 1999, most men with cerebrovascular disease received antiplatelet drugs (67%). However, a few received blood pressure-lowering drugs (50%) and statins (13%). By 2005, the use of all drug types had increased; at least half of the patients received each type of drug. However, only one-third of patients received all three medication types and combined blood pressure treatment was limited. Older age, a diagnosis of TIA rather than stroke and absence of co-existing coronary heart disease were associated with lower rates of use of specific medication categories. Despite improvements in secondary prevention medication use, there is scope for achieving the full potential of these medications, particularly by increasing combination blood pressure treatment and statin use and ensuring that older patients receive the benefits of prevention.