Hospital Stroke Research Articles

The effect of prognostic nutritional indices on stroke hospitalization outcomes

The effect of prognostic nutritional indices on stroke hospitalization outcomes

Abstract 4120785: Differential Cardiovascular Impact of ω-3 Fatty Acid in Patients at High Cardiovascular Risk in Asians versus non-Asians: Sub-analysis of the STRENGTH Randomized Clinical Trial

Background: Racial differences in lipid and cardiovascular risk profiles are well-established including for Asians. The STRENGTH trial found that ω-3 carboxylic acid (CA) formulation of eicosapentaenoic acid and docosahexaenoic acid did not result in significant changes in cardiovascular event rates compared with corn oil in statin-treated patients at high cardiovascular risk, however drug efficacy may vary by race. We evaluated and compared the cardiovascular treatment effect of ω-3 CA between Asians and non-Asians in this sub-analysis of the STRENGTH trial. Methods: The STRENGTH trial was a double-blinded 1:1 randomized controlled trial of 13,078 high cardiovascular risk patients enrolled during 10/30/2014-6/14/2017 at 675 centers. Efficacy of ω-3 CA for Asians (n=1,355) and non-Asians (n=11,723) and interactions between race and treatment effect were assessed. The primary endpoint is a composite of cardiovascular death, non-fatal myocardial infarction, stroke, coronary revascularization and unstable angina hospitalizations. Results: Key differences in baseline characteristics include Asians having significantly higher prevalence of men, secondary prevention, and lower total cholesterol, LDL, apoB100, and hsCRP. In Asians, ω-3 CA was associated with significantly lower primary endpoint during follow-up, with 81/698 events [Kaplan-Meier (KM) Estimate: 14.8%] in the ω-3 CA group, 103/657 events (KM Estimate: 20.4%) in the corn oil group, and hazard ratio (HR) 0.72, 95% CI 0.54-0.96, P=0.026 (Figure A). In non-Asians, there was not a significant difference in primary endpoint rates between the two groups, with 704/5841 events (KM Estimate: 15.6%) in the ω-3 CA group, 692/5882 events (KM Estimate: 15.9%) in the corn oil group, and HR 1.03 95% CI 0.93-1.14, P=0.60 (Figure B). There were significant interactions between race (Asian versus non-Asian) and treatment group for the primary endpoint (P=0.021) and non-fatal stroke (P=0.016) and remained significant after adjusting for other covariates. Conclusion: ω-3 CA was associated with significant reduction in major adverse cardiovascular events compared with corn oil in Asians but not in non-Asian patients with high cardiovascular risk. Further research is necessary to elucidate the mechanisms for potentially beneficial effects of ω-3 CA unique to Asian race.

Abstract 4115684: Outcomes Associated with Remote Monitoring without In-person Evaluations for Patients with Cardiovascular Implantable Electronic Devices

Introduction: Traditionally, patients with cardiovascular implantable electronic devices (CIEDs: pacemakers and implantable cardioverter-defibrillators) attend in-person visits at least annually, paired with remote monitoring (RM). Because similar data are obtained through RM and in-person visits, it is unclear whether routine in-person visits are necessary. Two small trials conducted outside the U.S. found no difference in clinical outcomes without routine in-person visits for patients engaged in RM, but their generalizability is uncertain. Research Aim: To determine whether routine visits for CIED care are associated with major adverse cardiac events (MACE) among patients in the U.S.’ largest public integrated health system, the Veterans Health Administration (VHA). Methods: We classified Veterans who received their CIED care within VHA and sent ≥1 RM transmission between 7/1/20-6/30/21 into one of three groups based on type of clinical encounters for CIED care: (1) any in-person, (2) virtual-only (telephone and/or videoconference), or (3) no in-person or virtual visits. Data were obtained from the VHA National Cardiac Device Surveillance Program and Corporate Data Warehouse. The primary outcome was MACE, a composite of all-cause mortality, stroke, and cardiac hospitalization, between 7/1/21-6/30/22. We performed multivariable logistic regression, adjusting for patient and device characteristics. Results: Of 40,366 patients, 27,298 (68%) had at least one in-person visit, 9,268 (23%) had only virtual visits, and 3,800 (9%) had neither. Mean age was 73 years, 97% were male, and 37% lived in rural areas. There were 6522 (23.9%) MACE events among patients who had in-person visits, 2116 (22.8%) among those who had only virtual visits, and 947 (24.9%) among those who had no visits. After multivariable adjustment, there was no significant association between encounter type and MACE [odds ratio 0.93 (95% CI: 0.85-1.01) for patients who had any in-person or virtual visits compared to those without]. Conclusion: Among patients engaged in RM, the odds of MACE was similar regardless of whether patients had in-person or virtual visits versus no visits. Although there could be unmeasured confounding, these results suggest routine in-person or virtual visits may no longer be necessary for CIED care with RM. Patients, clinicians, and healthcare systems could benefit by reducing low-value visits and re-focusing resources on visits that yield actionable interventions.

Abstract 4138246: Differences in Major Adverse Cardiovascular and Lower Limb Events and Guideline-Directed Medical Therapy Among Males and Females Within an Integrated Healthcare System

Background: Health disparities based on gender have been recognized as having a detrimental impact on care delivery and early identification of disease processes. Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic disease mortality. It is unclear what role, if any, gender plays in the diagnosis, treatment, and outcomes of PAD. Hypotheses: Females are less likely to have guideline-directed medical therapy (GDMT) and more likely to have major adverse cardiovascular events (MACE) and major adverse lower limb events (MALE) than males. Methods: The Intermountain Health electronic database was queried for patients meeting the following criteria: ≥18-years of age, PAD diagnosis between Jan 2006 to Dec 2021, seen at least once within the 18-months following initial PAD diagnosis, and had a symptom of PAD (see table). Follow-up GDMT, based on the 2016 AHA/ACC PAD guidelines, was determined by medication and procedures. Time to outcomes of MACE (all-cause death, MI, stroke, or unstable angina hospitalization) and MALE (limb ischemia, limb revascularization, or limb amputation) were examined using Cox-proportional hazard adjusted for GDMT, age, and prior CAD. Results: A total of 7522 patients had a symptomatic PAD diagnosis, with 38% female and 62% male. Females tended to be older (70.1±13.0 vs 68.6±11.7), more likely to be obese (25% v 21%), and less likely to have Afib (21% v. 24%), CAD (30% v 41%), MI (11% v 16%), renal failure (19% v 22%) but more likely to have a bleeding history (30% v 26%) (all p<0.01). Females were slightly less likely to have all the GDMT and yet had similar rates of referrals to specialists but higher rates to primary care providers (Table). After adjustment, females were less likely to have MACE (HR=0.94; 95% CI: 0.88, 0.99) and MALE (HR=0.85; 95% CI: 0.80, 0.92). Conclusion: Females had lower rates of MALE, driven by lower limb revascularization or amputation rates, and slightly lower rates, after adjustment, for MACE. This was observed despite the high rates of GDMT for both females and males (~80% in any category), with females having slightly less GDMT.

Abstract 4145880: Incidence and Outcomes of Acute Myocardial Infarction (AMI) in Hematological Malignancy Patients: Systematic review and Meta-analysis

Background: Patients with hematological malignancies may face increased cardiovascular risks, including acute myocardial infarction (AMI). This systematic review and meta-analysis aims to evaluate the incidence and outcomes of AMI in patients with hematological malignancies compared with the general population. Methods: A comprehensive literature search was conducted using the PubMed, Embase, and Google Scholar databases. Random effect models were utilized to calculate Mantel-Haenszel odds ratios (ORs) with 95% confidence intervals (CIs). The inverse variance method with DerSimonian–Laird (DL) of Tau2 was used to calculate standardized mean differences (SMDs) with CIs. Statistical significance was set at p < 0.05. The primary endpoint was the incidence of AMI, while secondary outcomes included in-hospital mortality, length of hospital stay, likelihood of undergoing invasive procedures, total hospital costs, bleeding events, and stroke outcomes. Results: Twenty-six articles, including approximately 6.33 million patients with hematological malignancies, were included in the meta-analysis. Hematological malignancies were not associated with an increased incidence of AMI compared with the general population (OR = 0.91; 95% CI 0.80 to 1.03; p<0.001). AMI in hematological malignancies was associated with an increased risk of in-hospital mortality (OR = 1.71; 95% CI 1.57 to 1.86; p<0.001), bleeding event (OR = 1.30; 95% CI 1.12 to 1.60; p<0.001), and stroke (OR = 1.24; 95% CI 1.09 to 1.42) compared with AMI in the general population. Patients admitted due to AMI in hematologic malignancies also experienced an increased length of stay (SMD = 0.25; 95% CI 0.20 to 0.28; p<0.001) compared with AMI in the general population. There was no significant difference between the two groups in terms of the likelihood of undergoing invasive procedures (OR = 0.62; 95% CI 0.56 to 0.69) or total hospital expenditure (SMD = 0.09; 95% CI -0.01 to 0.19). Conclusion: While hematological malignancies do not appear to increase the incidence of acute myocardial infarction (AMI), patients who experience AMI episodes are at higher odds of in-hospital complications.

Comparative analysis of risk factors and clinical outcomes in young patients with acute ischemic and hemorrhagic stroke

BackgroundStroke is a leading cause of death and disability worldwide and has significant socioeconomic impacts, particularly among young adults. This study focused on young adults (18–55 years) who experienced acute ischemic (AIS) or hemorrhagic stroke (HS) in Zanjan, Iran.MethodsA retrospective registry-based analysis was conducted using data from the Vali-e-Asr Hospital Stroke Center. A total of 5345 stroke patients were recorded between March 2016 and June 2023, and 616 young stroke survivors were included. Baseline demographic data, stroke risk factor data, functional status (modified Rankin scale (mRS) score, stroke severity (NIHSS score), treatment history, and mortality were analyzed. The statistical analyses included chi-square tests, independent t tests, and logistic regression.ResultsThe cohort comprised 525 AIS (85.23%) and 91 HS (14.77%) patients. Significant differences were observed between groups in terms of atrial fibrillation incidence, antiplatelet treatment history, hypertension, previous smoking, and recent stroke history. HS patients had a higher baseline NIHSS score (12.90 ± 6.04 vs. 7.69 ± 8.56, p < 0.05). In-hospital and three-month mortality rates were significantly greater in the HS group. Factors significantly associated with in-hospital mortality included hemorrhagic stroke, female sex, higher NIHSS score, and current smoking status. Lower odds of achieving excellent functional outcomes and functional independence at three months were noted for HS patients, influenced by NIHSS scores and prior health conditions.ConclusionYoung stroke patients, particularly those with hemorrhagic stroke, have higher mortality and poorer outcomes. The key risk factors included stroke type, NIHSS score, smoking status, and sex. Identifying and managing these factors could improve patient outcomes.

Increased risk of major adverse cardiovascular events in patients with deep and infected diabetes-related foot ulcers.

Diabetes-related foot ulceration (DFU) is associated with increased cardiovascular risk, but the mechanisms remain unclear. Inflammation and infection are mediators of CVD, which may be important in DFU. Prospectively collected data from patients attending a multidisciplinary DFU service were analysed. A deep ulcer was defined as one that reached muscle, tendon or deeper structures. Patients were categorised into four DFU groups: not deep and no infection (D-/I-), not deep but infected (D-/I+), deep with no infection (D+/I-) or deep with infection (D+/I+). Incident major adverse cardiovascular events (MACE) were defined as hospitalisation for myocardial infarction, stroke or transient ischaemic attack, or heart failure. Survival analyses were performed using the logrank test and multivariate Cox regression. Of 513 patients, 241 (47.0%) were in the D-/I- group, 110 (21.4%) were in the D-/I+ group, 35 (6.8%) were in the D+/I- group and 127 (24.8%) were in the D+/I+ group. MACE or all-cause mortality occurred in 75 patients (14.6%), and MACE alone occurred in 46 patients (9.0%) after median follow-up of 381 days (IQR 220-551) and 404 days (IQR 228-576), respectively. Infection was associated with significantly higher MACE or all-cause mortality (21.5% vs 8.7%; p<0.001) and MACE alone (13.5% vs 5.1%; p=0.003). MACE or all-cause mortality was significantly higher in the D+/I+ group (D-/I- 7.9%; D-/I+ 15.5%; D+/I- 14.3%; D+/I+ 26.8%; p<0.001), as was MACE alone (D-/I- 5.0%; D-/I+ 10.9%; D+/I- 5.7%; D+/I+ 15.7%; p=0.017). Infection and a deep ulcer were independent predictors of adverse outcomes. Deep and/or infected DFUs are associated with increased cardiovascular risk compared with DFUs that are not deep or infected. These findings provide a potential mechanistic explanation that requires investigation.

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p &lt; 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p &gt; 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3–97.3] and 82.8% [95% CI, 68.1–97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Are People Living With Dementia Receiving High Intensity Statin Therapy After Stroke? A Population-Based Cohort Study.

This Australian population-based study investigated statin intensity after hospitalization for ischemic stroke in a matched cohort of people living with and without dementia. We identified all patients aged ≥ 30 years hospitalized in the state of Victoria, Australia, for ischemic stroke from July 1, 2013 to April 30, 2018 from the Victorian Admitted Episodes Data set. People with dementia were matched 1:4 for sex, 5-year age group and index date ± 90 days with people without dementia. Records of statin dispensing within 60 days postdischarge were extracted from prescription claims data. The intensity of the first postdischarge statin dispensing was determined. Odds ratios for high versus low-moderate intensity and no statin dispensing were estimated using multinomial logistic regression adjusted for factors including age, sex, and comorbidity. The cohorts comprised 11,105 people (dementia: N = 2221; without dementia: N = 8884 and 52% were female. Compared to people without dementia, people with dementia had 35% (95% confidence interval [CI]: 24%-44%) lower odds of receiving a high intensity versus a low-moderate intensity statin and 54% (95% CI: 48%-59%) lower odds of receiving a high intensity versus no statin. Compared to men, women with and without dementia had 16% (95% CI: 5%-25%) lower odds of receiving a high- versus low-moderate intensity statin and 28% (95% CI: 19%-35%) lower odds of receiving a high intensity versus no statin. People living with dementia are less likely to receive high-intensity statins post-discharge compared to people without dementia. There is a gender gap in receipt of guideline-recommended high-intensity statin therapy for secondary prevention after ischemic stroke. Guidelines recommend all people with reasonable life expectancy receive a high-intensity statin after stroke to reduce the risk of recurrent stroke and other adverse cardiovascular events. More research is needed to understand why people living with dementia might not receive guideline recommended care, and how statin use and statin intensity impact the health outcomes of people living with dementia and stroke.

Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis.

For patients with asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction, current guidelines recommend routine clinical surveillance every 6 to 12 months. Data from randomized trials examining whether early intervention with transcatheter aortic-valve replacement (TAVR) will improve outcomes in these patients are lacking. At 75 centers in the United States and Canada, we randomly assigned, in a 1:1 ratio, patients with asymptomatic severe aortic stenosis to undergo early TAVR with transfemoral placement of a balloon-expandable valve or clinical surveillance. The primary end point was a composite of death, stroke, or unplanned hospitalization for cardiovascular causes. Superiority testing was performed in the intention-to-treat population. A total of 901 patients underwent randomization; 455 patients were assigned to TAVR and 446 to clinical surveillance. The mean age of the patients was 75.8 years, the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 1.8% (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after surgery), and 83.6% of patients were at low surgical risk. A primary end-point event occurred in 122 patients (26.8%) in the TAVR group and in 202 patients (45.3%) in the clinical surveillance group (hazard ratio, 0.50; 95% confidence interval, 0.40 to 0.63; P<0.001). Death occurred in 8.4% of the patients assigned to TAVR and in 9.2% of the patients assigned to clinical surveillance, stroke occurred in 4.2% and 6.7%, respectively, and unplanned hospitalization for cardiovascular causes occurred in 20.9% and 41.7%. During a median follow-up of 3.8 years, 87.0% of patients in the clinical surveillance group underwent aortic-valve replacement. There were no apparent differences in procedure-related adverse events between patients in the TAVR group and those in the clinical surveillance group who underwent aortic-valve replacement. Among patients with asymptomatic severe aortic stenosis, a strategy of early TAVR was superior to clinical surveillance in reducing the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes. (Funded by Edwards Lifesciences; EARLY TAVR ClinicalTrials.gov number, NCT03042104.).

Associations between heart rate, deformational echocardiographic parameters and clinical outcomes in patients with atrial fibrillation

Abstract Background The relationship between baseline heart rates and cardiac function in patients with atrial fibrillation (AF) remains unknown, as does its impact on long-term outcomes. Methods Patients with newly diagnosed AF and available echocardiography images were included. Conventional echocardiography measurement and myocardial deformation analyses using two-dimensional speckle-tracking echocardiography were performed during AF. Clinical endpoints included first-time hospitalization for ischemic stroke, heart failure (HF), all-cause mortality, and composite endpoint. Results Patients were categorized into groups according to baseline heart rates: 40-59, 60-69, 70-79, 80-89, 90-99, 100-109, 110-119, and ≥120 beats per minutes (bpm). As heart rates increased, there was a stepwise decrease of peak atrial longitudinal systolic strain (PALS: 14.6 ± 5.3%, 14.7 ± 5.5%, 14.1 ± 4.6%, 13.4 ± 4.7%,12.6 ± 4.9%, 12.1 ± 4.5%, 11.2 ± 5.2% and 10.8±4.1% in 40-59, 60-69, 70-79, 80-89, 90-99, 100-109, 110-119, and ≥120 bpm groups, respectively; P &amp;lt; 0.001)) and LV strain (-13.8 ± 3.9%, -14.5 ± 4.0%, -13.4 ± 3.4%, -13.4 ± 3.6%, -12.5 ± 3.6%, -11.9 ± 3.8%, -10.3 ± 3.8%, and -10.2 ± 3.8%, in 40-59, 60-69, 70-79, 80-89, 90-99, 100-109, 110-119, and ≥120 bpm groups, respectively; P &amp;lt; 0.001)(Figure). The lowest risk of composite endpoint was observed for patients whose heart rate between 60 to 69 bpm (Figure). Compared to the 60-69 heart rate group, faster heart rates were associated with increased risk of ischemic stroke (adjusted hazard ratios [aHR] 4.448 in the ≥120 bpm group), HF (aHR 1.909 in the ≥120 bpm group), mortality (aHRs 2.487, 2.810, 4.569, 4.760 in the 90-99, 100-109, 110-119, and ≥120 bpm groups, respectively), and composite endpoint (aHRs 2.034, 2.349, 3.492 in the 100-109, 110-119, and ≥120 bpm groups, respectively) (all P &amp;lt; 0.05). Conclusion In patients with AF, heart rate is closely linked to cardiac function and plays a pivotal role in long-term prognosis. Faster heart rates were associated with worse LA/LV functions and increased risk of clinical events. Favorable outcomes were found at heart rates below 100 bpm, with even better LA/LV function noted at heart rates below 80 bpm.

The Impact of Poor Air Quality on Hospitalisation of Multi-morbid Patients: A Systematic Review

Abstract Background Exposure to poor air quality worsen existing health conditions, particularly amongst vulnerable patients, leading to increased healthcare utilization. We conducted a systematic review to explore the impact of exposure to poor quality on healthcare requirements in multi-morbid patients. Methods We searched six major databases (Medline via Ovid, Embase via Ovid, Web of Science, CINAHL, Global Health, and Scopus) using search terms grouped into sets relating to ‘air pollution,’ ‘multimorbidity,’ “association” and ‘hospitalisation.’ We were interested in the impact of common air pollutants (PM2.5, PM10, SO2, NO2, O3, and CO) and articles were screened independently by two researchers. The review was registered with The International Prospective Register of Systematic Reviews (CRD42022369757) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results A total of nineteen studies were included. All six air pollutants increased hospitalisation amongst multi-morbid patients, especially those with diabetes and cardiovascular comorbidity. Females and the elderly (&amp;gt;65 years old) were the most vulnerable to the effects of air pollution, with an increase in hospitalisations of 9.23% and 6.35% when exposed to PM2.5 and PM10, respectively. Patients &amp;gt;65 years had a higher likelihood of hospitalisation for ischemic and haemorrhagic stroke when exposed to PM2.5 or PM10 at warm season. Patients (≥70 years) who had cardiovascular and pulmonary comorbidity were 3.9% more likely to be hospitalised for a cardiopulmonary event with a rise in NO2 levels. We found an intersectional effect (referred to as “the CADC effect” - Climatic changes, Air pollutant, Demographics, Chronic conditions) that influenced the likelihood of hospitalisation. Conclusions Future research is required to further understand this CADC effect in other high-risk population. Key messages • Females, elderly, those with cardiovascular, and pulmonary comorbidity are at the highest risk of hospitalisation with poor air quality. • The CADC effect explains the intersectional effect between hospitalisation in multimorbid patients, patients demographics and chronic conditions, and air pollution and temperature effects.

Association of lipid target achievement and cardiovascular outcomes following statin initiation: a population-based cohort study

Abstract Introduction Non-high density lipoprotein cholesterol (non-HDL-C) is increasingly incorporated into clinical practice guidelines along with low density lipoprotein cholesterol (LDL-C) to guide lipid-lowering therapy decisions. We aimed to examine patterns of LDL-C and non-HDL-C levels after statin initiation for primary prevention of cardiovascular disease (CVD), and their association with incident CV events. Methods We conducted a population-based cohort study of Ontario, Canada residents age ≥66 years who initiated a statin for primary prevention between January 1, 2012 and December 31, 2019. For those surviving 1-year after statin initiation, we determined the proportion with a lipid panel in the 1-year period after a statin was started. For those with a lipid panel, we used the lipid panel closest to the end of the 1-year period to categorize individuals based on the LDL-C and non-HDL-C thresholds in the 2021 Canadian Cardiovascular Society dyslipidemia guidelines (Table 1). We stratified by diabetes/chronic kidney disease (CKD) status. We evaluated the association between LDL-C/non-HDL-C category and a composite of all-cause mortality or hospitalization for myocardial infarction, stroke or revascularization (primary outcome). We also investigated the association between each category and each component of the primary outcome. The index date was the 365 days after a statin was initiated and follow-up was until December 31, 2020. We used a cause-specific hazards model for analysis, adjusted for clinical and sociodemographic confounders. Results Our cohort comprised 173,127 people. In the 1-year period after statin initiation, 72% of people had a follow-up lipid panel performed. Median follow-up after that was 2.5 years. Compared with those meeting both LDL-C and non-HDL-C targets, being above both targets was associated with an increased rate of the primary outcome for people without diabetes/CKD (HR 1.10, 95% CI 1.05 to 1.15) and those with diabetes/CKD (HR 1.16, 95% CI 1.09 to 1.23). Being at LDL-C target but above non-HDL-C target was associated with an increased rate of the primary outcome for people with diabetes/CKD (HR 1.16, 95% CI 1.03 to 1.30) but not for those without diabetes/CKD (HR 1.05, 95% CI 0.93 to 1.17). Conclusions In this population-based cohort, having an LDL-C and non-HDL-C above guideline-recommended targets after statin initiation was associated with an increased rate of adverse outcomes. These findings support the residual risk associated with incompletely controlled LDL-C or non-HDL-C levels after initiating statin therapy for primary prevention.Primary outcome associationsComponents of primary outcome

Readmission and mortality during the first year after an acute stroke: A prospective cohort study from Cameroon.

Hospital readmission after discharge for stroke is associated with high morbidity and mortality. There is a paucity of data on the burden of stroke readmission in most sub-Saharan African countries. We aimed to determine the rate, reasons and predictors of hospital readmission and the mortality rate within 12 months of discharge among stroke survivors in Cameroon. This prospective cohort included patients who survived hospitalization for an acute stroke and who were discharged from two referral hospitals in the capital city of Cameroon between January 2013 and December 2013.We performed logistic regression analysis to identify demographic and clinical factors associated with readmission within 1 year of discharge and causes of readmission. Of the 254 consecutive patients admitted for acute stroke, 198 were discharged alive. There were 107 (54%) males, and their mean age (SD) was 61.7 (13.9) years (range: 10 to 95 years). A total of 30 (15.2%) patients were readmitted following discharge from the index admission over a mean follow-up time of 286.9 (127.6) days. Of these, 14 (46.7%) were discharged and 16 (53.3%) died after readmission. Thirty percent (30%) of readmissions occurred within the first month. The most frequent causes of readmissions were infections (30%) and recurrent stroke (26.7%). Factors associated with readmission in bivariate analysis were initial admission temperature > 37.5°C (risk ratio [RR]: 1.3, p = 0.021) and initial admission Glasgow Coma Score < 14 (RR: p = 1.23, p = 0.019). After stratified adjustment for age and sex, temperature > 37.5°C (adjusted RR: 1.3, 95% CI: 1-1.7, p = 0.036) and GCS <14 (adjusted RR: 1.23, 95% CI: 1-1.6, p = 0.041) were associated with readmission. Readmission after discharge for stroke was common with nearly one third occurring within the first month and more than half dying following readmission. The most common causes of readmission were infections and recurrent stroke.

Combination of moderate-intensity statins and ezetimibe versus high-intensity statins alone for primary prevention of cardiovascular events

Abstract Background Combination of a moderate-intensity statin with ezetimibe can lead to similar reductions in cardiovascular events as monotherapy with a high-intensity statin in patients with established atherosclerotic cardiovascular disease (ASCVD). The comparative effectiveness of these two cholesterol-lowering strategies in the primary prevention setting is unknown. Purpose To compare incident ASCVD events associated with a combination of moderate-intensity statin and ezetimibe versus monotherapy with a high-intensity statin in adults without prior history of cardiovascular disease. Methods We conducted a new-user active comparator retrospective population-based cohort study in Canada. We included all adults aged ≥ 67 years (eligible for drug coverage) with a first prescription of either a combination of moderate-intensity statin with ezetimibe ("combination therapy") or high-intensity statin alone between January 2010 and December 2022. Patients were excluded if they had not received any prior lipid lowering therapies or had a history of myocardial infarction (MI), stroke, heart failure, peripheral vascular disease or prior coronary revascularisation at any time before or within 3 months of treatment initiation. The primary outcome was a composite of all-cause death, hospitalization for MI or stroke, or coronary revascularization. An inverse probability of treatment weighting propensity score was used to account for confounding (demographics, comorbidities, laboratory tests, other medications). Results Among 67,884 patients (mean age: 74.0±5.5y; 53% females), 8,798 (13%) initiated combination therapy and 59,086 (87%) initiated a high-intensity statin. At 1 year, after weighting, the mean achieved LDL-C was ~1.9 mmol/L in both groups. The median follow-up was 6.5 years. The cumulative incidence of the primary outcome at 10 years in the weighted cohort was 32.7% in the combination therapy group and 36.1% in the high-intensity statin group (HR: 0.87; 95% CI: 0.82 to 0.92; p&amp;lt;0.001; absolute risk reduction: 3.5%; 95% CI: 0.8 to 6.1; Figure 1). This result was primarily driven by a lower risk of all-cause death (HR: 0.85; 95% CI: 0.80 to 0.91; p&amp;lt;0.001; Figure 2) and stroke (cause-specific [cs] HR: 0.86; 95% CI 0.74 to 0.99; p=0.04), whereas no differences were observed in the risk of MI (csHR: 0.97; 95% CI: 0.82 to 1.15) or coronary revascularization (csHR: 0.97; 95% CI 0.85 to 1.11). Conclusion The combination of moderate-intensity statins with ezetimibe was associated with a lower risk of incident ASCVD compared with high-intensity statins alone among primary prevention patients in a real-world setting. These results were driven by a lower risk of all-cause death and stroke, but not coronary events. The influence of statin intolerance on the allocated strategy and adherence to therapy cannot be addressed in this analysis, which, along with verifying these estimates, may be best determined in a prospective randomized trial.

Comic-based consenting on patient-reported experience and outcome measures for transfemoral aortic valve implantation

Abstract Background The impact of an improved patient informed consent (IC) before transcatheter aortic valve implantation (TAVI) on patient-reported experience and outcome measures (PREMs and PROMs) as well as on clinical outcomes remains unclear. Purpose To investigate patient satisfaction, PREMs, PROMs and clinical outcomes in patients receiving additional illustrative graphic-based IC (comic group) compared to conventional IC (control group) for TAVI at two tertiary care centers as part of a randomised controlled trial ("TAVI-COMIC study"). Methods Adult patients undergoing elective TAVI were enrolled. Patient satisfaction and PREMs were assessed after providing IC, PROMs at 90 days after TAVI and clinical safety outcomes within 7 days after TAVI (Figure). Results Only 48 (32%) of all patients read the official usual patient information sheet. Of 299 patients undergoing TAVI, comic-based IC was performed in 152 (51%) patients. Patient satisfaction was significantly higher (29 [23-32] vs 25 [22-30] of a maximum of 32 points in the validated Client Satisfaction Questionnaire [CSQ], p&amp;lt;0.001) and anxiety was lower (34 [25-51] vs 39 [29-55], p&amp;lt;0.001 in the validated Spielberger State-Trait-Anxiety Inventory [STAI]) in the comic group. 92 (61%) patients in the comic group felt "relaxed" prior to the procedure compared to only 44 (30%) patients receiving conventional IC (p&amp;lt;0.001). 91 (60%) were "very satisfied" with the delivered patient IC compared to 28 (19%) patients in the control group (p&amp;lt;0.001). PROMs at 90 days were assessed in a subgroup of 198 (66% of total cohort) patients: The comic group had similar PROMs as the control group (e.g. general health condition, walking ability and rate of dizziness, syncope, helplessness, depression, dyspnea or angina). Clinical outcomes, such as bleeding, pneumonia, stroke, delirium, or TAVI unit and hospital length of stay, were similar in both groups. Conclusion Use of an alternative IC approach, such as medical graphic narratives, might significantly improve patient satisfaction and PREMs, while facilitating similar PROMs and procedural safety as conventional treatment strategies.

Lower rate of ischemic events with PCSK9 inhibition in patients with atherosclerotic cardiovascular disease but without prior ischemic events

Abstract Background Individuals with atherosclerotic cardiovascular disease (ASCVD) without prior ischemic events, such as myocardial infarction (MI), ischemic stroke (IS), or unstable angina (UA) hospitalization, are at very high risk for having an event. Purpose To estimate the impact of PCSK9 inhibitor (PCSK9i) therapy on ischemic events in this population. Methods Patients with ASCVD were initially selected from the Optum Research Database during Jan 2016 to Dec 2022. For selected patients the index (time zero for follow-up) was required to be in a period of ASCVD without prior ischemic events, however patients may have ischemic events after index. Determination of ASCVD and ischemic events was based on diagnosis and procedure codes. For the PCSK9i group, index was initiation of PCSK9i and information before index was examined to ascertain ASCVD and rule out prior ischemic events. For each patient in the PCSK9i group, up to 5 matching patients in the no-PCSK9i group were chosen based on propensity score (PS) distance, with maximum allowable PS distance of 0.1. Among all possible choices for index for the no-PCSK9i patient, the selected one minimized the PS-distance. The primary endpoint was defined as the composite of nonfatal MI, nonfatal IS, and all-cause death. In order to further reduce bias and ensure causally interpretable estimation, the G-computation methodology was employed by marginalizing the conditional treatment effect (as estimated by a Cox model) over the baseline characteristics. Two effects were estimated: intention-to-treat (ITT) where only the treatment assignment at index was considered as the intervention, and per-protocol (PP) where the effect of sustained treatment with PCSK9i over time was estimated. Results A total of 15,067 and 66,470 patients met the selection criteria for the PCSK9i and no-PCSK9i groups, respectively. Baseline characteristics were well-balanced at index. G-computation analysis resulted in estimated survival curves over time in the two groups for the ITT and PP scenarios (Figures 1 and 2). For the ITT scenario, the estimated 5-year event rate was 18.7% (95% confidence interval [CI]: 17.1%–20.1%) in the PCSK9i group and 28.4% (95% CI: 27.7%–29.1%) in the no-PCSK9i group. The implied relative risk reduction (RRR) and absolute risk reduction (ARR) were 34.3% (p&amp;lt;0.001) and 9.7% (p&amp;lt;0.001), respectively, in favor of the PCSK9i group. For the PP scenario, the estimated 5-year event rate was 10.7% (95% CI: 9.7%–11.7%) in the PCSK9i group and 28.8% (95% CI: 28.3%–29.5%) in the no-PCSK9i group. The implied RRR and ARR were 62.7% (p&amp;lt;0.001) and 18.1% (p&amp;lt;0.001), respectively, in favor of the PCSK9i group. Conclusions Initiation of PCSK9i in patients with ASCVD but without prior ischemic events is associated with significantly and substantially lower risk for ischemic events.Event Rates Intention-to-Treat ScenarioEvent Rates Per-Protocol Scenario

Anticoagulation and stroke in hospitalized patients newly diagnosed with secondary atrial fibrillation: a population-based cohort study

Abstract Background Atrial fibrillation (AF) can be triggered by acute precipitants, with reversion to sinus rhythm after the stressor resolves. This has been described as "secondary AF", to differentiate it from AF without acute provocation ("primary AF"). Objective To describe anticoagulation patterns and the risk of stroke following hospitalization with a new diagnosis of secondary AF, with comparison to a first hospitalization for primary AF. Methods We created a cohort of adults aged ≥66 years who were discharged alive from hospital after a first diagnosis of AF between April 1, 2013, and March 31, 2019. The main exposure was "secondary" AF, with "primary" AF serving as the comparator group. This was based on a validated approach utilizing the AF discharge diagnosis type. Patients were followed for 1 year. We used drug dispensation records to determine the proportion of people anticoagulated after discharge from hospital. We also identified hospitalizations for stroke. We used the cumulative incidence function to estimate the risk of stroke while not anticoagulated, while censoring on dispensation of anticoagulation and treating death as a competing risk. Inverse probability of censoring weights were used to reduce bias from informative censoring. Cause-specific hazards regression was used to estimate the hazard ratio (HR) for stroke associated with secondary AF (relative to primary AF) while accounting for differences in baseline characteristics and time-varying anticoagulation status. Results We identified 13,011 people with secondary AF and 11,065 with primary AF. People with primary AF were older (mean 79.5 yrs vs. 77.1 yrs for secondary AF), more likely to be female (58.6% vs. 42.3% for secondary AF), and more likely to have prior HF. Secondary AF was positively associated with prior bleeding, diabetes, ischemic heart disease, and peripheral vascular disease. Mortality was higher for people with secondary vs. primary AF: 1.7% (95%CI 1.5%-2.0%) vs. 0.7% (95%CI 0.6%-0.9%) respectively at 7 days, 4.2% (95%CI 3.9%-4.6%) vs. 2.5% (95%CI 2.2%-2.8%) at 30 days, and 16.1% (95%CI 15.5%-16.7%) vs. 14.6% (13.9%-15.2%) at 1-year post-discharge. The proportion of people who were dispensed anticoagulants within 7 days of discharge was lower for secondary than primary AF (26.9% vs. 68%), and this continued to be lower at one year (41.7% vs. 82.3%, p&amp;lt;0.001 for both comparisons). At 1 year, the risk of stroke in people who were not anticoagulated was 2.2% (95% CI 1.6-2.8%) after primary AF and 1.2% (95% CI 1.0-1.4%) after secondary AF (p&amp;lt; 0.001). Relative to patients with primary AF, the hazard of stroke (adjusted for baseline characteristics and time-varying anticoagulation status) was lower in patients with secondary AF (HR 0.74; CI 0.57-0.97; p= 0.03). Conclusion Secondary AF is associated with higher mortality, less anticoagulation, and a lower risk/ hazard of stroke than primary AF. These data can inform post-discharge care in people with secondary AF.Proportion anticoagulated over timeRisk of stroke without anticoagulation

Systematic Review: Comparative Efficacy and Safety of Losartan vs. Candesartan for the Treatment of Hypertension

Hypertension is one of the most significant modifiable risk factors for cardiovascular disease (CVD) and remains a leading cause of morbidity and mortality globally. Effective management of hypertension is essential for preventing comp lications such as stroke, myocardial infarction, and heart failure. Angiotensin II receptor blockers (ARBs) like losartan and candesartan are well-established therapeutic options for blood pressure (BP) control and are widely prescribed due to their favorable side-effect profiles and organ-protective properties. Despite being members of the same drug class, these ARBs differ in their pharmacokinetics, receptor binding affinity, and clinical efficacy. This systematic review aims to provide a detailed comparison of the efficacy and safety of losartan versus candesartan in managing hypertension. We conducted a comprehensive search of the PubMed, Embase, and Cochrane databases, retrieving studies published from 2000 to 2024 that compared the two ARBs directly in hypertensive populations. A total of 25 randomized controlled trials (RCTs) and observational studies, comprising more than 12,000 participants, were included in the analysis. The primary outcomes evaluated were the reduction in systolic and diastolic blood pressure, cardiovascular event prevention, and adverse event profiles. The results suggest that both losartan and candesartan effectively lower BP, but candesartan consistently demonstrated greater reductions in both systolic and diastolic BP compared to losartan. Candesartan also appeared to have superior cardiovascular outcomes, with a lower incidence of major cardiovascular events such as stroke, myocardial infarction, and heart failure hospitalizations. The safety profiles of both drugs were comparable, though losartan was associated with a slightly higher incidence of cough and discontinuation due to adverse events. Overall, candesartan may offer a slight clinical advantage over losartan, particularly in patients requiring more potent or sustained BP control. However, both drugs remain valuable options in the management of hypertension. Further long-term studies are recommended to confirm these findings and to investigate the potential benefits of each drug in specific patient subgroups.

Effects of glucagon-like peptide-1 receptor agonists on cardiovascular outcomes in high-risk type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

BackgroundGlucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been shown to provide cardiovascular benefits in patients with type 2 diabetes mellitus (T2DM). However, their cardiovascular protective efficacy in high-risk T2DM patients, particularly those with a history of cardiovascular events or severe chronic kidney disease, remains uncertain.MethodsA comprehensive search was conducted in PubMed, Embase, Web of Science, and The Cochrane Library to identify randomized controlled trials (RCTs) that evaluated the effects of GLP-1 RAs on cardiovascular outcomes in high-risk patients with T2DM. A random-effects model was used to calculate pooled hazard ratios (HRs) for cardiovascular outcomes. Subgroup analyses and GRADE assessment were also performed.ResultsNine RCTs involving 63,613 patients were included. GLP-1 RAs significantly reduced the risk of the primary composite outcome (HR: 0.86, 95% CI: 0.80–0.92), cardiovascular death (HR: 0.85, 95% CI: 0.78–0.93), all-cause death (HR: 0.87, 95% CI: 0.82–0.93), myocardial infarction (HR: 0.90, 95% CI: 0.82–0.98), stroke (HR: 0.85, 95% CI: 0.77–0.95), and heart failure (HF) hospitalization (HR: 0.90, 95% CI: 0.83–0.97). No significant difference in unstable angina (UA) hospitalization was observed (HR: 1.04, 95% CI: 0.95–1.15). Subgroup analyses indicated greater benefits with combination therapy, particularly in patients with chronic kidney disease. The quality of evidence was rated as “High” for six outcomes and “Moderate” for UA hospitalization.ConclusionsGLP-1 RAs significantly reduce cardiovascular risk in high-risk T2DM patients, especially with combination therapy and in those with chronic kidney disease. However, further research is needed to confirm their long-term effects.