Stroke Onset Research Articles

Physical activity and influencing factors in people post stroke or transient ischemic attack across diverse regions in Sweden.

Physical activity (PA) and sedentary behavior are key targets for secondary stroke prevention, yet their characteristics and contributing factors are not well understood. This study aims to explore PA and sedentary behavior in individuals' post-stroke or transient ischemic attack (TIA) and identify factors linked to low PA (≤5,000 steps/day) and prolonged sedentary time (≥8 h/day). A cross-sectional study comparing sensor-derived (activPAL) PA and sedentary time among community-dwelling individuals post stroke or TIA residing in diverse geographical regions of Sweden. Multiple logistic regression models were performed to determine potential factors associated with low PA and prolonged sedentary time. The study included 101 participants post-stroke (n = 68) and TIA (n = 33), with a mean age of 70.5 years (65% female), mostly with no or mild disability (91%), living in metropolitan (69%) and rural (31%) areas of Sweden. Most participants (72%) had ≥ 8 h of sedentary time per day and 38% performed ≤5,000 steps per day. Using a walking aid (OR = 11.43, p = 0.002) was independently associated with low PA, whereas contextual factors; living alone (OR = 3.49, p = 0.029) and living in metropolitan areas (OR = 2.79, p = 0.036), were associated with prolonged sedentary time. In this study encompassing people post stroke or TIA from diverse geographical regions across Sweden, PA was associated with mobility status whereas sedentary behavior was associated with contextual factors. The results also showed a large variation in PA highlighting the need for tailored strategies to promote PA post stroke or TIA.

Carrier frequency and incidence estimation of deficiency of adenosine deaminase 2 in the Chinese population based on massive exome sequencing data

Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive autoinflammatory disease characterised by early onset stroke, recurrent fever, and diverse vascular pathologies, caused by loss-of-function homozygous or compound heterozygous variants of ADA2. This research aimed to determine the carrier frequency and expected incidence of DADA2 in China, using massive exome sequencing (ES) data. A total of 50 likely pathogenic/pathogenic variants (LP/PVs) were identified among 69,413 Chinese individuals, including 20 novel and rare variants (<0.0022 % allele frequency), expanding the known spectrum of PVs in ADA2. The overall carrier frequency in the Chinese population was 1.05 % (732/69,413) and the estimated incidence of DADA2 was approximately one in 92,251 individuals. The present study provides an accurate estimation of the prevalence of DADA2 in China, supporting genetic counseling, early diagnosis treatment, and prognostic evaluation.

Chronic Illness and visiting clinic before hospitalization at the onset of Stroke: Shiga Registry

Abstract Background Prompt action at stroke onset is required to improve prognosis. Some previous studies indicated that visiting local clinics may initially delay access to specialized care. We examined the relationship between the presence of chronic diseases known as risk factors for stroke and visiting a local clinic before admission to the hospital for acute stroke care. Methods This study utilized data from stroke patients aged 18 and older who were registered in the Shiga Stroke and Heart Attack Registry (SSHR) from January 2011 to December 2015. We excluded cases with onset during hospitalization or those with impaired consciousness assessed by the Japan Coma Scale (JCS &amp;gt; =10). The presence of comorbid chronic diseases was determined based on the past history and medications presented at admission. Local clinics are defined as clinics or hospitals that are not equipped to provide acute stroke treatment. Multivariate logistic regression analyses, adjusting for sex, age, modified Rankin Scale score before onset, and stroke subtypes, were performed to calculate odds ratios and 95% confidence intervals for visiting a clinic before hospitalization according to the presence of chronic diseases such as hypertension, diabetes, dyslipidemia, and atrial fibrillation, respectively. Results Data from 11,111 out of 14,620 registered cases were analyzed. Among these participants, 5,774 had hypertension, 1,951 had diabetes, 2,111 had dyslipidemia, and 882 had atrial fibrillation. A total of 2,405 (21.6%) cases visited a local clinic at stroke on set. The adjusted odds ratios for visiting clinics by the presence of hypertension were (1.22, 95% CI: 1.11 -1.34), diabetes (1.14, 1.01-1.28), dyslipidemia (1.07, 0.95 -1.20), and atrial fibrillation (0.80, 0.67 -0.95). Conclusions The present study indicated that individuals with hypertension and/or diabetes are more likely to initially visit a local clinic at stroke onset, whereas those with atrial fibrillation were not. Key messages • Approximately 20% of mild stroke patients first consult local or primary care doctors at stroke onset. This trend was particularly observed in individuals with hypertension and diabetes. • Emphasizing the need for direct access to specialized emergency care for individuals with chronic diseases is important to avoid delays in acute stroke care.

Efficacy and safety of P2Y12 inhibitors plus aspirin versus aspirin alone in ischemic stroke or high-risk transient ischemic attack: a meta-analysis of randomized controlled trials

Abstract Background Patients with mild ischemic stroke or transient ischemic attack (TIA) have an increased risk of recurrent stroke within 90 days after the onset of the initial thrombotic event. Antiplatelet therapy plays an essential role in reducing the risk of stroke recurrence. However, data regarding the efficacy and safety of dual antiplatelet therapy (DAPT) with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy is limited. Purpose We performed an updated systematic review and meta-analysis to evaluate the effectiveness of DAPT versus aspirin monotherapy in patients with mild ischemic stroke or TIA in the light of new published evidence. Moreover, we investigated whether antiplatelet therapy started within 72 hours is effective in reducing recurrent stroke as compared to the conventionally used 24-hour time window for initiating DAPT. Methods PubMed/MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared DAPT with aspirin plus clopidogrel to aspirin alone started within 24 hours or 72 hours in patients with acute mild ischemic stroke or high-risk TIA from inception to December 31st, 2023. A random-effects model was used to pool risk ratios (RRs) and 95% confidence intervals (CIs) for clinical endpoints. Results Five RCTs with 27,563 patients were included in this study. DAPT significantly reduced the risk of recurrent stroke by 23% (RR: 0.77; 95% CI: 0.70-0.83; p&amp;lt;0.00001), ischemic stroke by 26% (RR: 0.74; 95% CI: 0.68-0.81; p&amp;lt;0.00001), and major adverse cardiovascular events (MACE) by 23% (RR: 0.77; 95% CI: 0.71-0.84; p&amp;lt;0.00001). However, DAPT was associated with a significantly increased risk of moderate or severe bleeding (RR: 2.19; 95% CI: 1.38-3.48; p=0.0009) and hemorrhagic stroke (RR: 2.08; 95% CI: 1.13-3.82; p=0.02). No significant differences were observed for all-cause death (RR: 1.28; 95% CI: 0.95-1.71; p=0.10), cardiovascular death (RR: 1.38; 95% CI: 0.81-2.33; p=0.23), and myocardial infarction (RR: 1.63; 95% CI: 0.77-3.46; p=0.20). We performed sensitivity analysis based on the hazard ratio reported by RCTs which showed comparable results. Subgroup analysis based on treatment onset time (therapy initiation within 24 hours of thrombotic event vs therapy initiation within 72 hours of thrombotic event) showed that both strategies were effective in reducing the risk of recurrent stroke. Subgroup analysis based on the duration of DAPT (21 days vs. 90 days) showed that DAPT for 90 days was associated with an increased risk of moderate or severe bleeding as compared to therapy lasting for 21 days. Conclusion DAPT with P2Y12 inhibitors and aspirin reduces the risk of recurrent stroke and MACE but is associated with an increased risk of moderate or severe bleeding.

Feasibility and end-user perceptions of a novel digital care assistant and support program for people after stroke or transient ischemic attack (CAPS)

Abstract Background The Care Assistant and support Program for people after Stroke (CAPS) or transient ischaemic attack (TIA) is a clinician-led program designed to improve the secondary prevention of stroke. The program combines person-centred goal setting and risk-factor monitoring through a web-based clinician portal, SMS goal-aligned messages, a mobile application (app), and a wearable device. We aimed to determine the feasibility of CAPS among people living with stroke or TIA, and clinicians who would deliver the program in future. Methods Open label single group pre-posttest mixed-methods evaluation of the 12-week program. Eligible lived-experience participants were recruited through the Australian Stroke Clinical Registry. Eligibility: diagnosis of stroke or TIA in preceding 6 months - 3 years, ≥18 years old, smartphone/tablet ownership, living in the community. Following surveys and interviews of lived-experience participants, ten clinicians experienced in stroke care were invited to participate in focus groups to discuss the program. We used descriptive statistics to evaluate feasibility outcomes, i.e. participant perceptions of usability, acceptability and satisfaction, and clinician perceptions on program design and delivery. Results From 600 invitations, 34 eligible participants commenced the program (27% female, 33% TIA, median 1.7 years from index event; one withdrew). Usability of the CAPS app was rated as ‘Good’ to ‘Excellent’ (System Usability Scale), with moderate sustained usage by study conclusion (&amp;gt;60%). Participants frequently reviewed their health data within the app (average twice a day/participant over 12 weeks), and entered their health measurements an average 73 times/participant. The majority (≥90%) of participants thought the program fitted well into their daily lives or helped engage them in self-monitoring, with 76% indicating they would use the program, if publicly available. Clinician participants included three nurses, three allied health professionals, two neurologists, a stroke consultant, and a general practitioner (GP) in focus groups. Overall, eight had positive perceptions of the CAPS program. Three clinicians indicated the measurements collected in the app captured "vital information", and five saw the value of CAPS to improve secondary prevention. Recommended modifications to the program included tracking atrial fibrillation and blood cholesterol. Seven believed participants would receive the most benefit from the program if delivered within three months post-discharge. Six indicated that GP-led multidisciplinary care was the best model to deliver CAPS. Conclusions The CAPS program was feasible to deliver and acceptable to people living with stroke or TIA. Clinicians saw the value of CAPS for secondary prevention, with feedback prompting further focus groups with GPs to develop the potential model of care. Findings have informed the design of a Phase II randomised feasibility trial.

SDS-Net: A Synchronized Dual-Stage Network for Predicting Patients Within 4.5-h Thrombolytic Treatment Window Using MRI.

Timely and precise identification of acute ischemic stroke (AIS) within 4.5h is imperative for effective treatment decision-making. This study aims to construct a novel network that utilizes limited datasets to recognize AIS patients within this critical window. We conducted a retrospective analysis of 265 AIS patients who underwent both fluid attenuation inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) within 24h of symptom onset. Patients were categorized based on the time since stroke onset (TSS) into two groups: TSS ≤ 4.5 h and TSS > 4.5 h. The TSS was calculated as the time from stroke onset to MRI completion. We proposed a synchronized dual-stage network (SDS-Net) and a sequential dual-stage network (Dual-stage Net), which were comprised of infarct voxel identification and TSS classification stages. The models were trained on 181 patients and validated on an independent external cohort of 84 patients using metrics of area under the curve (AUC), sensitivity, specificity, and accuracy. A DeLong test was used to statistically compare the performance of the two models. SDS-Net achieved an accuracy of 0.844 with an AUC of 0.914 in the validation dataset, outperforming the Dual-stage Net, which had an accuracy of 0.822 and an AUC of 0.846. In the external test dataset, SDS-Net further demonstrated superior performance with an accuracy of 0.800 and an AUC of 0.879, compared to the accuracy of 0.694 and AUC of 0.744 of Dual-stage Net (P = 0.049). SDS-Net is a robust and reliable tool for identifying AIS patients within a 4.5-h treatment window using MRI. This model can assist clinicians in making timely treatment decisions, potentially improving patient outcomes.

Clinical impact of combined assessment of the CHADS2 score and geriatric nutritional risk index on clinical outcomes in patients with lower extremity artery disease without atrial fibrillation

Abstract Background The CHADS2 score is a well-known risk score for ischemic stroke in atrial fibrillation (AF) patients. Recently, it has been reported that the CHADS2 score was associated with an increased risk of new-onset lower extremity artery disease (LEAD) in patients without AF, the association between the CHADS2 score and clinical outcomes in patients with LEAD undergoing endovascular treatment (EVT) without AF remains unclear. Furthermore, malnutrition assessed by the geriatric nutritional risk index (GNRI) has been reported to be predictive of clinical outcomes in patients with LEAD. However, there are limited studies regarding the association of combined assessment of the GNRI and CHADS2 score and clinical outcomes in patients with LEAD without AF. Purpose The purpose of this study was to investigate the association between the combined assessment of GNRI and CHADS2 score, and mortality of LEAD patients undergoing EVT without AF. Methods This retrospective study investigated 236 consecutive LEAD patients who underwent EVT without AF. CHADS2 scores were calculated by assigning one point for heart failure, hypertension, age ≥75 years, and diabetes; and assigning 2 points for a prior history of stroke or transient ischemic attack. The GNRI on admission was calculated as follows: [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)], and the CHADS2 score and GNRI were calculated for each patient. We scored GNRI by assigning 2 points to low GNRI (GNRI &amp;lt;82) and 1 point to intermediate GNRI (GNRI =82 to &amp;lt;92). We then calculated the CHADS2 plus GNRI score for each patient and then patients were divided into the high CHADS2 plus GNRI scoregroup (CHADS2 plus GNRI score&amp;gt; 2, n = 123) and the low CHADS2plus GNRI score group (CHADS2 plus GNRI score≤ 2, n = 113) according to the median CHADS2 plus GNRI score. We investigated the associations between all-cause mortality in patients with LEAD who underwent EVT and the CHADS2 plus GNRI score. Results The mean age was 71.9±10.4 years, and 66.9% were men. During the median follow-up of 752 (283–1472) days, 50 patients died. Kaplan-Meier curves revealed that the cumulative incidence of all-cause death was significantly higher in the high CHADS2 plus GNRI score group than in the low CHADS2 plus GNRI score group (log-rank p = 0.003). Furthermore, even in the multivariate analysis,after adjusting for other risk factors including hemodialysis and clinical frailty scale, CHADS2 plus GNRI score was independently associated with all-cause death (per one score increase, hazard ratio: 1.26, 95% confidence interval (CI) 1.01-1.56, P=0.038). Conclusions In LEAD patients who underwent EVT without AF, a higher CHADS2 plus GNRI score was associated with an increased risk of all-cause death. A Combined CHADS2 plus GNRI score assessment may be a useful prognostic marker in patients with LEAD without AF.

Safety of beta-blocker discontinuation in patients after acute coronary syndromes and preserved left ventricular ejection fraction: long-term clinical outcomes from the SPUM-ACS cohort

Abstract Background While beta-blockers have been shown to improve outcomes after acute coronary syndromes (ACS), most trials predate the advent of reperfusion therapy and modern secondary prevention. Recent trial data in the reperfusion era found no all-cause or cardiovascular mortality benefit in patients with a left ventricular ejection fraction (LVEF) &amp;gt;40%, while myocardial infarction and angina were reduced. We hypothesized that, in patients who receive optimal contemporary treatment following ACS and who have an LVEF &amp;gt;40%, beta-blocker discontinuation within 1 year after ACS is safe and non-inferior to beta-blocker continuation in terms of the 5-year incidence of major adverse cardiovascular events (MACE). Purpose We assessed the safety of beta-blocker discontinuation within 12 months following ACS in patients with an LVEF &amp;gt;40% at discharge, compared to continued long-term beta-blocker therapy, with respect to the 5-year incidence of MACE. Methods Data was derived from the Swiss Special Program University Medicine – Inflammation in ACS (SPUM-ACS) cohort (N=3,762), a multicenter prospective cohort of patients hospitalized for invasive management of ACS between 2009-2017. We included patients with an LVEF &amp;gt;40%, beta-blockers at discharge, and who completed the 5-year follow-up. Patients who continued beta-blockers at one year were compared with those who discontinued beta-blockers at any time throughout the first year after ACS using a target trial emulation design. Adjusted hazard ratios (aHR) were obtained with a Cox model using an inverse probability weighting adjustment for baseline characteristics including demographic parameters, comorbidities, and concomitant medication. The primary endpoint was 5-year MACE (cardiovascular death, myocardial infarction, stroke or transient ischemic attack, unplanned coronary revascularization, and hospitalization for unstable angina). Results Of 2,077 patients with an LVEF &amp;gt;40% and beta-blockers at discharge, 1,758 (85%) continued beta-blockers and 319 (15%) had discontinued beta-blocker therapy at one year. The 5-year risk between the discontinuation and continuation group was similar for the primary endpoint (14.5% vs 14.3%, respectively, aHR 1.00, 95%CI 0.73-1.36, p=0.98). All-cause mortality (aHR 1.08, 95%CI, 0.64-1.81, p=0.79) did not differ between both groups. In a subgroup analysis, there was no effect modification by LVEF, but some evidence for a higher risk of primary endpoint with beta-blocker discontinuation in STEMI (aHR 1.50, 95%CI 1.02-2.21) compared with NSTEMI (aHR 0.69, 95%CI 0.40-1.19, P interaction = 0.022). Conclusion Beta-blocker discontinuation within 12 months following ACS in patients with an LVEF &amp;gt;40% was not associated with an increased risk of MACE at 5 years, compared to long-term continuation of beta-blocker therapy. In the absence of a dedicated randomized controlled trial, beta-blocker discontinuation may be safe, especially after NSTEMI.Kaplan-Meier plot: probability of MACE

Implementation of prasugrel and prognostic outcomes after percutaneous coronary intervention for myocardial infarction: a nationwide observational study

Abstract Background Prasugrel has shown superior efficacy and similar safety compared to ticagrelor for patients with acute coronary syndrome treated with percutaneous coronary intervention (PCI) in a randomised setting. Since 2020, prasugrel has been recommended over ticagrelor in our country. It remains unknown if these recommendations have been implemented, and if the findings from the randomised trial can be expanded to an all-comer population. Purpose To assess the implementation of prasugrel and compare effectiveness and safety between prasugrel and ticagrelor in PCI-treated, all-comer patients with myocardial infarction (MI). Methods From January 1st, 2019, to December 31st, 2021 patients with MI treated with PCI were identified by use of nationwide health registries. We included patients who were alive and claimed a prescription of prasugrel or ticagrelor within 7 days from discharge. Incidence rates per 100 person-years (IRs) 6 months from discharge were calculated for a composite outcome of all-cause mortality, recurrent MI (&amp;gt;28 days after index MI), and stroke (MACE), all-cause mortality alone, ischaemic events (a composite of recurrent MI and stroke) and bleeding leading to hospitalisation. We illustrated a Kaplan Meier curve with log-rank test and a cumulative incidence curve with Gray’s test and performed Cox models to assess adjusted comparative differences of the outcomes between prasugrel and ticagrelor after adjusting for age, sex, relevant comorbidities, and calendar year. Results We identified 14,365 PCI-treated patients with MI, of whom 13,887 (96.7%) were alive 7 days from discharge. After excluding patients who did not collect a P2Y12 inhibitor (n=1097 [7.9%]) or collected clopidogrel within 7 days from discharge (n=2696 [21.1%]), the final study population counted 10,094 patients of whom 2045 (20.3%) patients collected prasugrel and 8049 (79.7%) ticagrelor. Figure 1 shows the temporal use of P2Y12 inhibitors. The mean age was 64.4 (±11.7) years and 23.9% were female. Patients with prasugrel were less often ≥75 years old (16.3% vs. 23.2%), female (22.1% vs. 24.3%), and had fewer comorbidities (hypertension, hypercholesterolemia, diabetes, stroke or transient ischaemic attack, bleeding, and prior PCI) than ticagrelor-treated patients. Figure 2 illustrates IRs of the outcomes and Kaplan Meier and cumulative incidence curves. Prasugrel treatment was associated with reduced risk of MACE (HR 0.67 [95% CI 0.47-0.95]) and ischaemic events (HR 0.68 [0.47-0.97]) compared with ticagrelor after adjustment, and there were no differences in all-cause mortality or bleeding (Figure 2). Conclusion Prasugrel use increased from 1% to 44% from 2019 to 2021, but most all-comer patients with MI were treated with ticagrelor after PCI. Prasugrel showed lower risk of MACE and ischaemic events without excess in bleeding 6 months post-discharge compared to ticagrelor, consistent with the findings of a previous randomised trial.Temporal use of potent P2Y12 inhibitorsSix-months outcomes of potent P2Y12i

Concomitant left atrial appendage occlusion and transcatheter aortic valve replacement among patients with atrial fibrillation: an updated systematic review and meta-analysis

Abstract Background Atrial fibrillation (AF) is a prevalent arrhythmia in patients undergoing transcatheter aortic valve replacement (TAVR). Left atrial appendage occlusion (LAAO) has emerged as a viable strategy to prevent stroke in selected patients with AF. While both devices can be implanted simultaneously during a single procedure, the safety and efficacy of this approach remain uncertain. Purpose This study aims to evaluate the efficacy and safety of concomitant LAAO in patients with AF and aortic valve disease undergoing TAVR. Methods We conducted a systematic review and meta-analysis of randomized controlled trials and observational studies that compared concomitant TAVR and LAAO with isolated TAVR. The study's primary outcomes were all-cause mortality, stroke or transient ischemic attack (TIA), and major bleeding. We established a minimum follow-up time of six months. Results Three studies met our eligibility criteria, including one randomized controlled trial and two observational studies. The meta-analysis included 570 patients, 249 (44%) who underwent LAAO and TAVR, with a mean follow-up of 16.3 months. In the overall population, there was no significant difference between the groups in all-cause mortality (relative risk [RR] 0.95; 95% confidence interval [CI] 0.67-1.35; p = 0.78; figure 1A), major bleeding (RR 1.15; 95% CI 0.75-1.77; p = 0.51; 1B), and stroke or TIA (RR 0.70; 95% CI 0.33-1.45; p = 0.33; figure 1C). Conclusion In conclusion, concomitant LAAO and TAVR did not demonstrate discernible clinical differences compared to isolated TAVR in patients with AF and aortic valve disease. We recommend that this therapeutic approach be individualized until more robust data become available.

The long-term usage of statin prevents adverse events in patients with atrial fibrillation

Abstract Background The effectiveness of statins in preventing adverse cardiovascular events in individuals with atrial fibrillation (AF) has remained uncertain. This study aimed to assess whether statin use could lead to better outcomes among individuals with AF. Purpose Our study aimed to investigate the relationship between statin use and cardiovascular outcomes in patients with newly-diagnosed AF. Methods This study used the National Health Insurance Research Database (NHIRD) in Taiwan. We enrolled 397,787 patients with AF from January 1st, 2012, to December 31st, 2020. Patients with AF were divided into 2 groups (statin user and statin non-user), and the risks of composite outcomes (ischemic stroke, hemorrhagic stroke and transient ischemic attack [TIA]), all-cause death and major adverse cardiovascular events (MACEs, which encompassed cardiovascular death, non-fatal myocardial infarction and heart failure hospitalization) were analyzed. Propensity score matching with time-dependent analysis was examined. Results We analyzed 288,958 patients with newly diagnosed AF (mean age, 73 years; 44% women; mean CHA2DS2-VASc score, 3.5). Compared with patients without statin use, statin user had a lower risk of composite endpoint, which included ischemic stroke, hemorrhagic stroke and TIA. (adjusted hazard ratio, 0.92; 95% confidence interval, 0.88-0.95; p &amp;lt; 0.01) after adjusting for patients’ age, gender, CHA2DS2-VASc score, cardiovascular medications, and comorbidities. In regard to all-cause mortality, statin users exhibited a 62% risk reduction compared to statin non-users (hazard ratio, 0.38; 95% confidence interval, 0.37-0.39; p &amp;lt; 0.01). Statin use was also associated with reduced incidence of MACEs (hazard ratio, 0.70, 95% confidence interval, 0.68-0.71; p &amp;lt; 0.01). In the subgroups stratified by CHA2DS2 VASc score, statin therapy was particularly effective for patients with CHA2DS2-VASc scores 0-3 for composite endpoints but consistently reduced all-cause mortality and MACEs across all score categories. Conclusions Among patients with newly diagnosed AF, statin use was associated with a lower risk of ischemic stroke, hemorrhagic stroke, TIA, all-cause mortality and MACEs.

The association of obesity and in-hospital outcomes among patients undergoing ablation for atrial fibrillation: a propensity-score matched analysis

Abstract Background Obesity is a strong risk factor for atrial fibrillation (AF), and it can affect the prognosis of AF. However, the impact of obesity (BMI≥30 kg/m²) on postoperative complications after AF ablation has not been extensively studied. We aimed to evaluate the association of obesity with in-hospital outcomes among patients with AF who ablation procedures. Methods The study utilized the National Inpatient Sample (NIS) database 2016-2020. Patients were divided into obese and non-obese groups and matched with propensity score matching (1:1). This matching involved adjusting for baseline variables (including age, gender, primary expected payer, race, and median household income) and comorbidities (including diabetes, hypertension, hyperlipidemia, history of coronary artery bypass grafting (CABG), chronic kidney disease, hyperthyroidism, cardiomyopathy, prior stroke or transient ischemic attack, heart failure with preserved ejection fraction (HFpEF), heart failure with reduced ejection fraction (HFrEF), heart valve disease, coronary artery disease, chronic obstructive pulmonary disease (COPD), alcohol misuse, anemia, and smoking). Furthermore, a weighted analysis was conducted utilizing weights provided by the NIS, and multivariate logistic regression was used to calculate the odds ratio. Results A total of 29,440 patient with AF who underwent ablation were included. After propensity matching, (8,110 in obese and 8,110 in non-obese group) the baseline characteristics were not significantly different between the two groups. Obesity was independently associated with higher risk of pseudoaneurysm, hematoma, postoperative anemia, acute kidney injury, vasopressor need, mechanical ventilation, pulmonary embolism, and ischemic stroke in patients who underwent ablation for AF (Figure 1). In addition, obese group had significantly higher length of stay (median and IQR 2 [1-3] vs 2 [1-4]) and total charges (median and IQR: 131,248$ [95,303-197,784] vs 143,693$ [102,720-206728]) compared to non-obese group (p&amp;lt;0.001). However, in-hospital mortality was not significantly different between the two groups. Conclusion In patients who underwent AF ablation, obesity is associated with significantly higher risk of post-operative complications, as well as increased LOS and total hospital charges.

Machine learning to predict incident atrial fibrillation in patients with acute stroke: FIND-AF STROKE

Abstract Background Atrial fibrillation (AF)-related strokes have a high rate of recurrence, and are associated with substantial morbidity, disability, healthcare expenditure, and mortality.(1-3) Detection of AF promises opportunity to prevent recurrent stroke through conversion of antiplatelet to anticoagulant therapy,(4,5) but use of extended monitoring has cost implications.(6) Thus accurately identifying patients with stroke at high risk for AF is important but previous previous models have been developed in small, unrepresentative cohorts.(7) Purpose To develop and validate a simple novel decision support tool for prediction of incident AF after hospitalisation with stroke through machine learning. Methods We developed the model (FIND-AF STROKE) in UK secondary care and death certificate-linked primary care health record data from individuals aged ≥30 years without known AF hospitalized with a stroke or transient ischaemic attack (Jan 2, 1998 to Feb 28, 2022), randomly divided into training (80%) and testing (20%) datasets. We evaluated logistic regression and random forest models for prediction of 2-year AF risk in the testing dataset with internal bootstrap validation, and compared against the CHA2DS2VASC score. Youden index was used to set a threshold for higher and lower risk. Results Of 35 530 UK individuals (mean age 72.1 (SD 12.7) years, 50.9% women), 1742 (4.8%) had developed incident AF at 2 years. Using feature importance a parsimonious version of the model was created requiring only age, sex, ethnicity (white versus other) and five comorbidities. In the testing dataset prediction performance for the random forest algorithm (area under the receiver operating characteristic (AUROC) 0.710, 95% CI 0.685 – 0.736) was superior to the CHA2DS2VASC score (0.645, 95% CI 0.617-0.672) (Figure 1). The threshold for higher risk using the Youden index was 4.81% which resulted in a negative predictive value of 97.6%, sensitivity 0.712, specificity 0.583. Of the post-stroke patients 44% were labelled at higher risk of AF, who were older, had a higher prevalence of comorbidities, and a 3.3-fold higher incidence of AF post-stroke, than those identified as lower risk (Table 1). Conclusions The machine learning FIND-AF STROKE decision support tool can accurately identify individuals at risk of incident AF after stroke to enable a targeted and cost-effective approach to extended monitoring. Validation within cohorts that have undergone extended monitoring post-stroke will give a more accurate estimation of yield at different risk thresholds.Figure 1

Direct synchronized cardioversion not independently associated with infarcts on cerebral magnetic resonance imaging and clinical outcomes in patients with atrial fibrillation

Abstract Background Direct synchronized cardioversion (DCV) is frequently performed in atrial fibrillation (AF). In general, DCV is considered a safe procedure. A rare, but feared complication following DCV is an overt ischemic stroke resulting from embolization of a left atrial clot to the cerebral circulation. Purpose The aim of the present study was to assess the association of DCV with infarcts on brain magnetic resonance imaging (bMRI) and clinical outcomes. Methods 2386 patients of the Swiss AF cohort were included. 1731 patients were evaluated by bMRI. DCVs were recorded by questionnaire. Patients were categorized by number of DCVs performed before enrollment (0,1,≥2). BMRI were conducted at baseline and after 2 years (n=1227) and analyzed for large noncortical or cortical infarcts (LNCCI) and small noncortical infarcts (SNCI). Clinical outcomes were recorded during follow-up. Associations of DCV and outcome-measures were assessed by multivariate analyses. Results There was no independent association between the number of DCV and infarct prevalence (LNCCI + SNCI) on baseline bMRI (DCV 1 vs. 0: OR 0.95 [95% CI 0.73-1.26]; DCV ≥2 vs. 0: OR 1.04 [0.73-1.51]) or between DCV performed during follow-up and new infarcts on bMRI at 2 years (OR 1.46 [0.54-3.31]). DCVs were not associated with overt stroke or transient ischemic attack (DCV 1 vs. 0: HR 1.35 [0.87-2.03]; DCV ≥2 vs. 0: HR 1.54 [0.95-2.49]), hospitalization for heart failure (DCV 1 vs. 0: HR 1.03 [0.80-1.33]; DCV ≥2 vs. 0: HR 1.03 [0.77-1.37]), or death (DCV 1 vs. 0: HR 0.85 [0.67-1.09]; DCV ≥2 vs. 0: HR 0.92 [0.70-1.22]). Conclusions There was no association between DCV performed before enrollment and cerebral infarcts on baseline bMRI or between DCV performed during follow-up and new infarcts at 2 years. Moreover, DCV were not associated with clinical events.

Cardiac autonomic changes after stroke

Abstract Introduction There is a highly complex and clinically important relationship between the cardiac and the nervous system, called the heart-brain axis [1]. Therefore, acute brain damage may lead to alterations in cardiac function due to changes in the autonomic nervous system[2,3]. Novel computerised biosignal analysis techniques and advanced biosignal assessment could provide a valuable tool to sensitively analyse cardiac autonomic function (CAF). CAF can be characterized by two complementary digital biomarkers, periodic repolariation dynamics (PRD) and deceleration capacity (DC). The aim of this study was to determine CAF by means of PRD and DC in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) and to analyze them according to their relationship with specific cardiac (high-sensitive Troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NT-pro BNP)) and stroke (location, type, severity) characteristics. Methoden / Methods Between February 22, 2021, and May 5, 2023, 282 patients after an AIS or TIA were enrolled in the study. During the inpatient stay, all relevant parameters were recorded and stored in a database. To assess CAF, a 30-minute biosignal measurement was performed with a high resolution (1kHz) electrocardiogram (ECG). Cardiac autonomic biomarkers, PRD and DC, were calculated semiautomatically afterwards from patients. Results Fifteen ECGs were excluded due to poor recording quality. Consequently, data from 261 AIS and 21 TIA patients were analyzed. A total of 105 patients (37.2 %) had pathological PRD (≥ 5.75 deg2) and/or DC (≤ 2.5 ms), 78 patients (27.7 %) had pathological PRD, and 57 patients (20.2 %) had pathological DC. The median PRD was 3.13 deg2 and the median DC was 5.30 ms (see Figure). There were no significant differences in the distribution of PRD and DC between male and female patients (PRD p = 0.38, DC p = 0.30), and between AIS and TIA patients (PRD p = 0.13, DC p = 0.66). Patients with middle cerebral artery (MCA) infarction had significantly higher median PRD values (3.56 deg2 [IQR 1.51 - 6.59 ] vs. 2.81 deg2 [IQR 1.15 - 5.99], p = 0.047) and lower median DC values (4.66 ms [IQR 2.65 – 7.76] vs. 6.11 ms [IQR 3.15 – 10.61], p = 0.011) than patients with stroke located in another cerebral regions (see Figure). Patients with pathological PRD or DC had significantly higher hsTnT (13.50 ng/l [IQR 9.7 – 24.1] vs. 11.05 ng/l [ IQR 7.13 – 16.23], p &amp;lt; 0.001) and NT-pro BNP (269.00 ng/l [IQR 117.50 – 687.00] vs. 125.50 ng/l [IQR 57.00 – 288.25], p &amp;lt; 0.001) values. Conclusions The study showed that a considerable proportion, more than one third of all patients, had evidence of cardiac autonomic dysfunction after acute cerebral ischaemia. Of particular interest, PRD was higher and DC was lower in patients with MCA ischaemia, reflecting a potentially higher cardiac risk profile. Cardiac autonomic dysfunction was also associated with increased hsTnT and NT-proBNP levels.

Health-related quality of life and long-term incidence of major adverse events in patients with acute coronary syndromes

Abstract Background Assessing health-related quality of life (HRQoL) in patients with acute coronary syndromes (ACS) could provide insight into predicting major adverse cardiovascular events (MACE) and all-cause death. Purpose To investigate the association of baseline HRQoL and its change within the first year post-ACS with the incidence of MACE and all-cause death. Methods Participants in the SPUM-ACS study, a multicenter cohort of patients hospitalized for ACS at four Swiss university hospitals from 2007 and 2021 and followed-up for a median duration of 6.6 years, were evaluated for HRQoL at baseline and one-year post-discharge using the EQ-5D-3L index and visual analogue scale (VAS). The EQ-5D-3L index is derived from five health dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Baseline HRQoL and its change within the first year post-ACS, alongside the individual health dimensions, were analyzed in relation to the risk of subsequent MACE (composite of myocardial infarction, stroke or transient ischemic attack, coronary revascularization, and cardiovascular death) and all-cause death using Cox proportional hazards models, adjusting for sociodemographic, lifestyle factors, and medical history. Results 2499 patients with ACS (mean age 62±12 years, 80% males), primarily undergoing percutaneous coronary revascularization, were included. Over a median follow-up of 6.6 years, 25% experienced MACE and 13% died from any cause. Overall, HRQoL improved in the first year post-ACS, with the EQ-5D-3L index increasing from 0.74 to 0.81 and the VAS from 68 to 76 (p&amp;lt;0.001). At baseline, 80% reported some problem in at least one health dimension, mainly anxiety/depression (36%), pain/discomfort (35%), and mobility (27%). By the first year, 58% had no problem or improved in one or more dimensions; however, 38% declined in at least one dimension, particularly in pain/discomfort (26%), or anxiety/depression (16%). The baseline VAS, but not EQ-5D-3L index, was inversely associated with the hazard of subsequent MACE and all-cause death (HR=1.06 [1.01, 1.11] per 0.1-unit and 1.10 [1.03, 1.19] per 10-unit decrease, respectively). Problems with pain/discomfort were associated with MACE (HR=1.20 [1.00, 1.44]); and mobility, self-care and usual activities with all-cause death (HR=1.36 [1.04, 1.79], 1.44 [1.04, 1.98] and 1.37 [1.04, 1.80], respectively) (Figure 1). First-year EQ-5D-3L index and VAS change were inversely associated with the hazard of MACE (HR=1.11 [1.04, 1.18] per 0.1-unit and 1.16 [1.07, 1.25] per 10-unit decrease) and all-cause death (HR=1.13 [1.04, 1.23] per 0.1 and 1.17 [1.06, 1.30] per 10-unit decrease, respectively) (Figure 2). Conclusion HRQoL at baseline and its change within the first year after ACS are associated with the risk of adverse events, suggesting HRQoL might be a valuable predictive indicator for long-term outcomes in patients with ACS.Figure 1Figure 2

Cost-Utility Analysis of Low-Dose Pioglitazone in a Population With Prediabetes and a History of Stroke or Transient Ischemic Attack.

Pioglitazone significantly reduces the risk of stroke in people with diabetes, and in those with prediabetes, it markedly reduces the risk of stroke/myocardial infarction and new-onset diabetes. Low-dose pioglitazone provides most of the clinical benefits of high-dose pioglitazone, with fewer adverse effects. We report an economic evaluation of the cost-effectiveness of low-dose pioglitazone versus placebo from a Canadian public payer perspective in 2023 Canadian dollars. A Markov model was developed at a lifetime horizon with an annual cycle length and 5 health states (event-free, myocardial infarction, stroke, new-onset diabetes, and death). Transition probabilities were extracted from the IRIS (Insulin Resistance Intervention in Stroke) trial. Health state costs and utilities were based on public sources. Annual discount rates of 1.5% were applied in the reference-case analysis. Probabilistic analyses were conducted to deal with parameter uncertainty through 5000 simulations. The costs were estimated as $24 887 (interquartile range [IQR], $14 632-$41507) for low-dose pioglitazone and $57 301 (IQR, $48 730-$67368) for placebo, resulting in a cost saving of -$30 287 (IQR, -$43 374 to -$14 587) in favor of low-dose pioglitazone. Quality-adjusted life years were estimated as 25.99 (IQR, 24.56-26.81) for the low-dose pioglitazone and 19.44 (IQR, 18.68-20.13) for placebo, resulting in a difference of 6.37 (IQR, 5.07-7.36) in favor of low-dose pioglitazone. Consistent findings were observed from scenario analyses and 1-way probability sensitivity analyses. Holding across a wide range of values in modeling parameters, low-dose pioglitazone is found as the dominant strategy versus a placebo.

Arterial floating mural thrombi are a characteristic imaging pattern in SARS-CoV-2-related ischemic stroke.

Acute ischemic stroke (AIS) is a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to explore neurovascular imaging patterns in patients with SARS-CoV-2-related AIS. We retrospectively analyzed clinical and radiological data of patients hospitalized with AIS and a positive PCR test for SARS-CoV-2 prior to AIS onset. The control group comprised of AIS patients from a pre-COVID-19 pandemic period matched for gender and age. Thirty-five SARS-CoV-2-related stroke patients, and 35 controls were included. Fifty-seven percent of SARS-CoV-2 patients had either mild or asymptomatic disease. A distinctive imaging pattern of floating arterial mural thrombus was detected in 5 patients of the SARS-CoV-2 group. In 4 patients thrombus was attached to a stenotic atherosclerotic plaque in the proximal internal carotid artery. In the 5th patient a cardiac CTA showed multiple floating thrombi in the descending aorta. In the control group, floating thrombus was only detected in one patient. Treatment with dual antiplatelet therapy was associated with thrombus dissolution and good clinical outcome. Patients with floating thrombi had a longer time from SARS-CoV-2 diagnosis to stroke onset (mean 7.4 versus 3.4 days). Floating arterial mural thrombi attached to atherosclerotic plaques are unique characteristic source of AIS in SARS-CoV-2 patients. They may lead to ischemic stroke in patients with mild or asymptomatic infection up to 1-2 weeks from SARS-CoV-2 diagnosis. Patients with embolic AIS and SARS-CoV-2 diagnosis should perform high resolution cranio-cervical vascular imaging to evaluate floating thrombi as a potential embolic source.

Performance of Atrial Fibrillation Burden Trends for Stroke Risk Stratification.

Atrial fibrillation (AF) is associated with an increased risk of stroke, yet the limitations of conventional monitoring have restricted our understanding of AF burden risk thresholds. Predictive algorithms incorporating continuous AF burden measures may be useful for predicting stroke. This study evaluated the performance of temporal AF burden trends as predictors of stroke from a large cohort with insertable cardiac monitors. Using deidentified data from Optum Clinformatics Data Mart (2007-2019) linked with the Medtronic CareLink insertable cardiac monitor database, we identified patients with an insertable cardiac monitor for AF management (n=1197), suspected AF (n=1611), and cryptogenic stroke (n=2205). Daily AF burden was transformed into simple moving averages, and temporal AF burden trends were defined as the comparison of unique simple moving average pairs. Classification trees were used to predict ischemic stroke, and AF burden significance was quantified using bootstrapped mean variable importance. Of 5013 patients (age, 69.2±11.7 years; 50% male; CHA2DS2-VASc, 3.7±1.9) who met inclusion criteria, 869 had an ischemic stroke over 2 409 437 days total follow-up. Prior stroke or transient ischemic attack (variable importance, 13.13) was the number 1 predictor of future stroke followed by no prior diagnosis of AF (7.35) and AF burden trends in follow-up (2.59). Temporal proximity of AF and risk of stroke differed by device indication (simple moving averages: AF management, <8 days and suspected AF and cryptogenic stroke, 8-21 days). Together, baseline characteristics and AF burden trends performed optimally for the area under the receiver operating characteristic curve (0.73), specificity (0.70), and relative risk (5.00). AF burden trends may provide incremental prognostic value as leading indicators of stroke risk compared with conventional schemes.

The Burden of Food Insecurity on Quality of Life in Adults with Diabetes.

Background: This study aimed to investigate the relationship between food insecurity and physical- and mental-health-related quality of life in adults with diabetes. Methods: Using two years of national Medical Expenditure Panel Survey data (2016-2017), we investigated the relationship between food insecurity and physical-health-related (PCS) and mental-health-related (MCS) quality of life in adults with diabetes. PCS and MCS were measured with the Short-Form 12 health survey and food insecurity was measured with the USDA 10-item adult scale. Analyses were weighted to represent the US adult population. Adjusted linear regression models, including covariates of age, gender, education, race/ethnicity, marital status, region, poverty level, employment status, health insurance, and comorbidities were used. Results: After adjustment, food-insecure adults with diabetes maintained significantly lower quality of life compared to food-secure adults with diabetes (PCS: -3.44, 95%CI -4.63, -2.25; MCS: -5.37, 95%CI -6.68, -4.06). This drop in PCS was larger than the drop for chronic conditions, including arthritis (-3.77, 95%CI -5.02, -2.52), emphysema (-2.82, 95%CI -5.12, -0.53), stroke (-2.63, 95%CI -4.11, -1.15), cancer (-2.59, 95%CI -4.00, -1.17), and heart attack (2.58, 95%CI 4.68, 0.48). Similarly, the drop for MCS was larger than for chronic pain (-2.37, 95%CI -3.24, -1.50) and arthritis (-1.31, 95%CI -2.28, -0.33). Conclusions: Food insecurity was associated with a significant reduction in both physical- and mental-health-related quality of life in adults with diabetes, with a magnitude of effect greater than adjusted estimates for the drop in quality of life for key chronic conditions. Addressing food insecurity through integration of social and medical care may lead to improvements in quality of life for adults with diabetes.