Guidelines For Prevention Of Stroke Research Articles

Prevention of perioperative ischemic stroke after non-cardiac and non-neurosurgical operations in the light of the Scientific Statement and Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack AHA/ASA 2021. Part 2: Perioperative antithrombotic therapy, diagnosis, treatment

One of the possible measures that can enhance the quality of medical care, reduce the number of adverse outcomes, and also achieve target values for the use of reperfusion methods of treatment for acute ischemic stroke is to improve the system of care for patients with in-hospital ischemic stroke. One type of in-hospital stroke is perioperative stroke that develops during or 30 days after surgery. Since the publication in 2014 of the last fundamental work on the prevention of perioperative stroke, the approaches to primary and secondary prevention, diagnosis, conservative and reperfusion treatment of ischemic stroke have been seriously modified. The numerous changes have created the preconditions for a revision of existing approaches to providing care for patients with perioperative ischemic stroke. In 2021, updated documents from foreign researchers/associations on the perioperative ischemic stroke in non-cardiac and non-neurosurgical patients were published. The second part of our review presents current data on the perioperative antithrombotic prophylaxis, clinical and instrumental diagnosis, treatment and organization of care for perioperative ischemic stroke in this category of patients. The issues of using reperfusion treatment methods in non-cardiac and non-neurosurgical patients with perioperative stroke, such as systemic thrombolytic therapy and endovascular interventions, are discussed in detail, including the world experience of their “offlabel” use.

Folic acid supplementation for stroke prevention: A systematic review and meta-analysis of 21 randomized clinical trials worldwide

Background & aimsThe AHA/ASA guidelines for primary stroke prevention are almost a decade old. The current recommendation regarding folic acid supplementation is based on only 8 clinical trials, and an additional 13 folate trials have been published since then. This meta-analysis aims to fill in critical evidence gaps by comprehensively evaluating 21 published trials with particular attention given to identifying the true influences through stratification. MethodsPubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched from inception to April 4, 2023. This study included all randomized controlled trials (RCTs) of folic acid with stroke as one of the reporting endpoints. Relative risks and 95% confidence intervals were used to assess the association between folic acid supplementation and the risk of stroke in a random-effects model. ResultsResults from the 21 pooled RCTs totaling 115,559 participants showed that folic acid supplementation significantly reduced the risk of stroke by 10% (RR 0.90, 95%CI 0.83 to 0.98). Subgroup analyses showed that folic acid efficacy was greater in areas without fortified grain or with partially-fortified grain (RR=0.83, 95% CI 0.75 to 0.93; RR=1.04 in areas with grain fortification, P-interaction=0.003). In this group, folic acid supplementation was most efficacious in those without a history of stroke or myocardial infarction (RR=0.77, 95% CI 0.68 to 0.86; RR=0.94 for participants with a history of stroke or myocardial infarction, P-interaction=0.008). The efficacy of folic acid remained consistent regardless of baseline folate levels, folic acid dosage, baseline vitamin B12 levels, vitamin B12 dosage, homocysteine reduction, intervention duration, and whether folic acid was taken alone or in combination (all P-interaction>0.05). All 21 trials were free of attrition bias and reporting bias, and there was no significant publication bias. ConclusionsThis is by far the largest meta-analysis of RCTs regarding folic acid supplementation and stroke, demonstrating the overall benefit of folic acid for stroke prevention. Grain fortification and history of stroke or myocardial infarction may be the most important influences on the efficacy of folic acid for stroke prevention.

Abstract WP278: Trends in GLP1RA and SGLT2i Use in Ischemic Stroke Patients With Diabetes

Background: The current AHA stroke prevention guidelines give Class 1 recommendations that patients with AIS and diabetes should receive glucose-lowering agents with cardiovascular benefit to reduce risk of MACE. The ADA recommends in patients with ASCVD, when prevention of further vascular events is the priority, a GLP1RA should be added; and when concern for heart failure or chronic kidney disease is the priority, a SGLT2i should be added. Objective: Among a cohort of patients with diabetes presenting with AIS, we analyzed rates of GLP1RA and SGLT2i use during hospitalization and/or outpatient follow-up. Methods: A retrospective review of AIS patients at a comprehensive stroke center between May 2016 and October 2022 was conducted using an institutional registry. Patients were identified to have diabetes as derived by the Charlson Comorbidity Index ICD 10 codes E10 through E14. We then identified patients receiving GLP1RA or SGLT2i and evaluated trends over time. Results: 4131 patients were identified of which 2045 (49.4%) had a diagnosis of diabetes. Of these patients 60/2045 (2.9%) were on GLP1RA while 35/2045 (1.7%) were on SGTLi for total of 4.6%. Annual trends were 2016 6/220 (2.7%) and 1/220 (0.4%), in 2017 6/347 (1.7%) and 3/347 (0.8%), in 2018 6/377 (1.6%) and 5/377 (1.3%), in 2019 3/240 (1.2%) and 1/240 (0.4%), in 2020 9/335 (2.7%) and 10/335 (3.0%), in 2021 11/322 (3.4%) and 10/322 (3.1%), in 2022 19/205 (9.2%) and 5/205 (2.4%) for GLP1RA and SGLT2i, respectively. Conclusions: In this retrospective analysis of 4131 AIS cases, use of GLP1RA and SGLT2i prior to 2019 remained around 2-3%. Following publication of the 2021 stroke prevention guidelines, GLP1RA use increased in 2022 to 9%. However, the study highlights the still-low rates of use of secondary MACE prevention despite Class 1 recommendations. This analysis serves as a call to attention that improving treatment of diabetes with ASCVD risk-reduction is a potential area of improvement.

Abstract TP272: Project Echo’s Beneficial Effect on Stroke Prevention Education for Healthcare Professionals

Introduction/Background: Project ECHO (Extension for Community Healthcare Outcomes) is a telehealth initiative that connects specialists with healthcare providers (HCPs) through videoconferencing, enabling knowledge-sharing and skill-building to improve preventative patient care in underserved areas This program was implemented in a study in Western Michigan concerning primary stroke prevention in vulnerable populations including women, African Americans, and Latinx patients. Research Questions/Hypothesis: We hypothesized that the program would effectively increase understanding among HCPs of effective risk-factor modifications in these populations. Goals/Aims: The study aimed to implement ECHO to increase access to stroke-preventative education for HCPs who serve vulnerable populations. These populations usually lack primary stroke prevention knowledge tailored to their individual risk factors. Methods/Approach: Cornwell Health conducted 5 didactic sessions with these goals in focus. We used participant surveys conducted before/after the program to assess the program’s efficacy. The curriculum focused on lifestyle modifications and covered 2013/2014 AHA stroke prevention guidelines and 2013 AHA/ACC guidelines to reduce cardiovascular risk. Results/Data: A 40% response rate was achieved from HCP participants. The average number of correct answers on the surveys out to 10 increased from 6 ± 1.2 questions on the pre-survey to 6.5 ± 1.0 on the post-survey. Confidence in counseling patients on risk-factor modification increased from 18.8% to 40.6%. Additionally, 87.5% of participants expressed interest in future Project ECHO programs on primary stroke prevention. Conclusion: The ECHO platform was beneficial concerning HCP understanding of risk-factor modifications in primary stroke prevention, confidence in counseling patients, and evaluation of the program’s educational value. The ECHO platform proved to be instrumental in reaching these outcomes and can be implemented in various capacities relating to community outreach and education.

Use of Oral Anticoagulants in Patients with Atrial Fibrillation: Preliminary Data from the Italian Atrial Fibrillation (ITALY-AF) Registry.

Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment. The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword. Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001). A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.

Prevention of perioperative ischemic stroke after non-cardiac and non-neurosurgical operations in the light of the Scientific Statement and Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack AHA/ASA 2021 Part 1: Definition, risk factors, pathogenesis, prognosis, principles of pre- and intraoperative prevention

Perioperative ischemic stroke is a potentially fatal complication that greatly increases the risk of poor outcome in surgical patients. Despite the relatively low prevalence among patients undergoing non-cardiosurgical and non-neurosurgical interventions (about 0.1–1.0 %), the total number of annually developing perioperative ischemic strokes in patients of this profile is high due to the large number of operations performed in the world. Since the publication in 2014 of the last fundamental work on the prevention of perioperative stroke, approaches to primary and secondary prevention, diagnosis, conservative and reperfusion treatment of ischemic stroke have been seriously modified. The numerous changes that have taken place have created the prerequisites for revising existing approaches to providing care for perioperative ischemic stroke. In 2021, updated documents of foreign researchers/ associations on the problem of perioperative ischemic stroke in non-cardiac and nonneurosurgical patients were published. This review, which consists of two parts, presents current data that summarizes the most relevant information on this topic. The first part of the review outlines the general provisions on perioperative ischemic stroke (definition, risk factors, pathogenesis, predictive models), strategies for pre- and intraoperative prevention.

Suboptimal lipid management in patients with acute ischemic stroke

ObjectiveLipid-lowering drugs are among the most widely used drugs in cardiovascular prevention. Statins are often abandoned due to side effects, or under dosed, leading to unreached LDL-cholesterol goals and increased occurrence of cardiovascular events. MethodsWe included hospitalized patients with an ischemic stroke or transient ischemic attack. Of 92 patients, low density lipoprotein cholesterol (LDL-C) levels and lipid lowering therapy at admission and discharge were assessed. Based on their cardiovascular risk before the current event according to the most recent European guidelines, LDL-C targets were determined. Low, moderate, high and very high risk corresponded with LDL-C targets below 116, 100, 70 and 55 mg/dL respectively. ResultsBefore current event, 59 (64%) were very high, 21 (23%) high, 11 (12%) moderate and 1 low risk patients and eight patients were treated with low, 23 moderate, and 21 high intensity lipid-lowering therapy. Upon admission, 75 patients had insufficiently managed LDL-cholesterol levels, yet 39 of them were taking lipid lowering therapy. Only eight of the 21 patients on high intensity lipid lowering therapy reached their LDL-C target. During hospitalization 40 patients were switched to a high-intensity statin. Thirty-three patients switched from no treatment or a lower-intensity to a moderate-intensity lipid lowering therapy. Three were dismissed with low-intensity lipid lowering therapy, and five in association with Ezetimibe. Three patients had documented statin-intolerance. ConclusionIn this study, LDL-cholesterol was insufficiently managed according to international guidelines for prevention of ischemic stroke. Further optimization of lipid management in primary and secondary prevention and the use of higher intensity lipid lowering therapy in clinical practice is mandatory.

Diabetes and Stroke: What Are the Connections?

Stroke is a major cause of death and long-term disability worldwide. Diabetes is associated with an increased risk of cardiovascular complications, including stroke. People with diabetes have a 1.5-2 times higher risk of stroke compared with people without diabetes, with risk increasing with diabetes duration. These risks may also differ according to sex, with a greater risk observed among women versus men. Several mechanisms associated with diabetes lead to stroke, including large artery atherosclerosis, cerebral small vessel disease, and cardiac embolism. Hyperglycemia confers increased risk for worse outcomes in people presenting with acute ischemic stroke, compared with people with normal glycemia. Moreover, people with diabetes may have poorer post-stroke outcomes and higher risk of stroke recurrence than those without diabetes. Appropriate management of diabetes and other vascular risk factors may improve stroke outcomes and reduce the risk for recurrent stroke. Secondary stroke prevention guidelines recommend screening for diabetes following a stroke. The diabetes medications pioglitazone and glucagon-like peptide-1 receptor agonists have demonstrated protection against stroke in randomized controlled trials; this protective effect is believed to be independent of glycemic control. Neurologists are often involved in the management of modifiable risk factors for stroke (including hypertension, hyperlipidemia, and atrial fibrillation), but less often in the direct management of diabetes. This review provides an overview of the relationships between diabetes and stroke, including epidemiology, pathophysiology, post-stroke outcomes, and treatments for people with stroke and diabetes. This should aid neurologists in diabetes-related decision-making when treating people with acute or recurrent stroke.

Females are less likely to receive best medical therapy for stroke prevention before and after carotid revascularization than males

BackgroundCurrent professional guidelines recommend best medical therapy (BMT) with statin agents and antiplatelet therapy for primary and secondary stroke prevention in patients with carotid artery stenosis. We aimed to assess the association of patient sex with preoperative BMT in patients undergoing carotid revascularization. MethodsWe performed a retrospective review of Vascular Quality Initiative patients who underwent carotid endarterectomy or carotid artery stenting between January 2003 and February 2022. Multivariable logistic regression models were used to assess the association of patient sex with preoperative BMT after adjusting for sociodemographic, comorbidity, and disease severity characteristics. In-hospital outcomes were assessed by sex and preoperative BMT status. ResultsOf 214,008 patients who underwent carotid revascularization, 38.7% (n = 82,855) were female and 61.3% (n = 131,153) were male. Overall, 77.2% (n = 63,922) of females were on preoperative BMT, compared with 80.4% (n = 105,375) of males (P < .001). After adjusting for baseline differences, females had 11% lower odds of being on BMT compared with males (adjusted odds ratio, 0.89; 95% confidence interval, 0.86-0.91). Postoperatively, females had 18% lower odds of being prescribed BMT than males (adjusted odds ratio, 0.82; 95% confidence interval, 0.79-0.84). In-hospital stroke (1.20% vs 1.51%), death (0.37% vs 0.66%), and stroke/death (1.46% vs 1.98%) were all significantly lower for patients on BMT (all P < .001). ConclusionsThere is a significant discrepancy in the proportion of females versus males receiving preoperative BMT for stroke prevention before carotid artery revascularization. In-hospital outcomes are worse in patients without BMT, highlighting the importance of raising awareness and implementing targeted interventions to improve preoperative adherence to stroke prevention guidelines.

Consensus Recommendations for Managing Childhood Cancer Survivors at Risk for Stroke After Cranial Irradiation: A Delphi Study.

There is insufficient evidence to support stroke prevention guidelines for childhood cancer survivors (CCS) treated with cranial irradiation for CNS tumors or other childhood cancers involving the CNS. We used a systematic consensus-building methodology to develop expert recommendations and define areas of controversy in managing asymptomatic CCS at risk for stroke. A Delphi process was used to query a multispecialty panel of 45 physicians from the United States/Canada, with expertise in CCS, about their stroke screening and management practices (imaging, referrals, laboratory testing, and medications). Three iterative rounds of anonymous, scenario-based questionnaires, building on panelists' aggregate responses, were used to reach consensus (≥90% agreement), agreement (89%-70% agree), or to understand the rationale for disagreement (<70% agree). All 45 physicians participated in the first 2 rounds and 44 in the third. Panelists reached consensus on indications for referral to neurology and laboratory screening for modifiable cerebral vascular disease (CVD) risk factors in most scenarios. Panelists agreed that aspirin therapy is not recommended in the scenario of normal neuroimaging (86% agreed). Decisions about aspirin therapy in scenarios with abnormal neuroimaging were deferred to specialists; almost all agreed with not using aspirin for cavernomas with no evidence for previous hemorrhage (93%) and using aspirin for both large vessel CVD (93%) and small vessel CVD with evidence of previous stroke (86%). Clinical decisions that remain controversial (less than 70% agreement) include neuroimaging to screen asymptomatic CCS for CVD, referral to neurology for cavernomas, aspirin use in the setting of cavernomas with previous hemorrhage, or with evidence for small vessel CVD and no previous stroke, and indications for statins. Overall, pediatric neurologists/neuro-oncologists and radiation oncologists were more likely to advocate for screening and interventions. Despite lack of evidence to guide the management of CCS at risk for stroke, expert recommendations and rationale developed by consensus methodology are helpful to support clinical decision-making.

Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women.

Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.

Expert Opinion on the Use of Novel Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation for the Primary Care Setting in India: A Literature Review.

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia encountered in clinical practice, is linked with substantial morbidity and mortality due to accompanying risk of stroke and thromboembolism. Patients with AF are at a five-fold higher risk of suffering from a stroke. Anticoagulation therapy, with either vitamin K antagonists or novel oral anticoagulants (NOACs), is a standard approach to reduce the risk. Consultant physicians (CPs) in India are the primary point of contact for the majority of patients before they approach a specialist. The CPs may face challenges in screening and diagnosing AF patients. The apprehensions associated with managing AF patients with anticoagulants, further add to the challenges of a CP. This review aimed to identify the key decision points for the CPs to diagnose AF and initiate anticoagulation in patients with non-valvular AF (NVAF) and bring to the table a simplified recommendation supported by expert opinion and guidelines for stroke prevention in NVAF patients.

Abstract P239: Dietary Behavior Interventions And Outcomes In Stroke Survivors: A Scoping Review

Purpose: Secondary stroke prevention is an essential but unmet need for stroke survivors. Current secondary stroke prevention guidelines from the American Heart Association recommend following a Mediterranean-type diet to reduce recurrent stroke risk. However, there is a lack of published data on dietary behavior interventions and outcomes among stroke survivors. Therefore, we conducted a scoping review to characterize published dietary behavior interventions and outcomes among community-dwelling stroke survivors to identify gaps in scientific knowledge. Methods: PubMed was used to find research articles published between January 2000 and April 2021. To be included, articles must have undergone peer-review and described both a dietary intervention and dietary outcome among community-dwelling stroke survivors. Study characteristics and dietary outcomes were extracted by 3 team members for studies that met inclusion criteria. Results: 649 articles were initially identified but 637 were excluded based on eligibility criteria. Study characteristics and outcomes of the 12 included studies are described in the table. All studies (9 randomized controlled trials, 3 cohort studies) delivered multimodal health behavior interventions that included a dietary component. Interventions were delivered weekly to every other month, lasted 1-24 months, and provided 1-132 contact hours. Dietary outcomes included food frequency questionnaires and self-reported fruit, vegetable, salt, or fat consumption. Eight studies reported improvement in dietary outcomes; 6 of which reported ≥16 contact hours. Conclusions: This review provides support for the efficacy of dietary behavior interventions in stroke survivors. Intervention format and outcomes varied greatly, which impedes the ability to determine efficacy of dietary interventions in this population and represents a gap in scientific knowledge. Comparative effectiveness studies that compare outcomes across existing interventions may narrow this knowledge gap.

Cost-effectiveness of apixaban versus other oral anticoagulants and aspirin for stroke prevention in atrial fibrillation in indian subcontinent

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Pfizer Ltd Background/Introduction Non-vitamin K antagonist oral anticoagulants (NOACs) are class I recommended by various guidelines for stroke prevention in atrial fibrillation. NOACs are associated with comparable or lower risk of stroke / systemic embolism and significantly lower major bleeding as compared to VKAs. Despite the fact that NOACs have demonstrated safety and efficacy in stroke prevention in AF by various randomized clinical trials and real-world evidences, the pharmacoeconomic data of NOACs in stroke prevention is lacking in India. In view of the higher initial and long-term cost of the NOAC therapy, it is important to analyze the cost effectiveness of such therapy to ensure wider acceptance and compliance to medication since majority of population in India is self-paying. Purpose The aim of this study was to evaluate the cost-effectiveness of apixaban versus other NOACs available in India (dabigatran and rivaroxaban), warfarin and aspirin for stroke prevention in atrial fibrillation from the healthcare providers’ and patients’ perspectives in the government healthcare as well as the private healthcare facilities across Indian subcontinent. Methods A Markov model was constructed using six-week cycle length over a lifetime horizon by including the available data from RCTs and real-world analyses of all NOACs. The clinical consequences of AF included in the analysis were stroke (ischemic and hemorrhagic), systemic embolism, bleeding (intracranial hemorrhage, other major and clinically relevant non-major), myocardial infarction, mortality and morbidity associated with NVAF not on anticoagulant. Innovator brands of NOACs were considered for this analysis, as NOACs are not under price control in India unlike warfarin and aspirin. Model outputs included quality-adjusted life years (QALY), life years gained, direct medical costs and incremental cost-effectiveness ratios (ICERs). Additional sensitivity and scenario analyses were conducted to test the robustness of the outcomes. Results From healthcare provider’s perspective irrespective of private medical facility or the government healthcare facilities, Apixaban was dominantly associated with cost-saving over other OACs. Apixaban was cost effective as compared to warfarin from patients’ perspective at the private medical facilities. Apixaban was cost-effective compared to dabigatran and rivaroxaban from patients’ perspective in the RWE-based analysis. Conclusion We conclude that apixaban is cost saving (less costly and more effective) compared to warfarin, aspirin and other NOACs from healthcare providers’ perspective. Apixaban may be a cost-effective alternative to dabigatran and rivaroxaban from patients’ perspective as per the RWD-based cost-effectiveness analysis. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare professionals and decision-makers. Abstract Figure. Incremental cost-effectiveness ratios

Abstract 47: Project TURNIP: Teleproctoring Of Rural Stroke Patients With Advanced Nurse Practitioner

Introduction: Prisma Health Tuomey (PHT) is a rural-based spoke hospital, with advanced Nurse Practitioners (ANP). Prisma Health Richland (PHR) is an urban-based hub hospital with access to vascular neurologists. In this ongoing project we evaluated the effectiveness of Zeriscope, a web-based, HIPAA compliant, teleproctoring platform, for ANP evaluation of etiology of ischemic stroke. Methods: PHT uses a web-based, HIPAA compliant, telemedicine platform, Zeriscope, to provide a live interactive video stream to PHR, a certified Comprehensive Stroke Center 45 miles away. Zeriscope uses a mobile exam headset, comprised of a camera attached to a cellphone and an audio headset, to provide two-way audio and visual communication between an APP and a board-certified vascular neurologist (Figure). The care was provided in inpatient setting with full access to neuroimaging, vascular imaging, cardiac imaging, and long-term monitoring. Patients evaluated directly by teleneurology platform in the PHT emergency room for TPA and thrombectomy were transferred to PHR and excluded from the teleproctoring assessment. Results: Fifty-two ischemic stroke and TIA patients (age 67.8 ± 12.7, 52 % African American, 69 % Males) were evaluated and treated in 4-month period from April to August 2021. Patients underwent a standardized stroke work-up to determine stroke etiology, which was classified by TOAST criteria (11.8% LAA, 19.6% Cardioembolic, 27.5% Lacunar, 39.2% Cryptogenic and 1.9% Undetermined). All patients received best medical management based on the secondary stroke prevention guidelines. To date, no patients experienced complications or were readmitted or needed transfer to a stroke center. Conclusion: Tele-proctoring is a feasible method of delivering stroke care that has not been previously implemented in a rural hospital. The use of Zeriscope was practical and effective in determination of ischemic stroke etiology and implementation of best practice guidelines.

Unfulfilled potential for secondary prevention of cognitive decline in individuals with covert brain infarcts: A population‐based study

AbstractBackgroundModifiable cardiometabolic risk factors account for about 25% of all dementia, including Alzheimer’s disease. Risk factor control is therefore pivotal, particularly in patients with high risk of dementia after stroke. However, 15‐20% of elderly individuals have brain infarcts on routine MRI that have not produced notable stroke symptoms (‘covert brain infarcts’ [CBI]), and in whom risk factors consequently may not be treated optimally.MethodWe included 5934 participants of the population‐based Rotterdam Study who underwent routine brain MRI and cognitive assessment between 2005‐2016 (mean age 65 years, 55% women). Clinical stroke symptoms were ascertained through interview and medical records review. In individuals with CBI, we determined the extent to which cardiometabolic risk factors (systolic blood pressure, LDL‐cholesterol, serum glucose) are managed according to AHA/ASA guidelines for secondary stroke prevention.ResultOf 507 patients with brain infarction on MRI, 395 (78%) had not had prior clinical stroke. Prevalence of CBI increased steeply with age, from 2% at age 45‐49 to 20% after age 85, and was associated with worse performance on a cognitive assessment battery (β[95%CI]=‐0.19[‐0.32;‐0.06]). 34% of participants &gt;60 years with CBI had one or more untreated, modifiable cardiometabolic risk factors, compared to 9% of participants with prior clinical stroke, and optimal risk factor control was twice as likely after clinical stroke than with covert brain infarcts (28 vs. 13%). Among individuals with CBI, those with suboptimal cardiometabolic risk management did worse on cognitive testing, notably in the memory domain (global cognition– β[95%CI]=‐0.27[‐0.65;0.12]; memory– β=‐0.40[‐0.73;‐0.08]). Similar differences were seen when additionally examining lifestyle factors (obesity and smoking). Of participants with CBI, less than half (45%) were using antithrombotic medication, compared to 88% after clinical stroke. The percentage of undertreated individuals was similar when comparing the earlier (2005‐2010) with the later years of the study (2011‐2016).ConclusionIn one third of individuals with covert brain infarcts, cardiometabolic risk factor management does not align with secondary stroke prevention guidelines, potentially resulting in poorer cognitive function. These findings should prompt further study into the optimal secondary preventive strategies for this large group of elderly individuals with undiagnosed covert brain infarcts.

Effectiveness of direct oral anticoagulants in obese adults with atrial fibrillation: an overview examining the evidence from international systematic reviews and meta-analyses

Abstract Background Obesity may influence the pharmacology of direct oral anticoagulants (DOAC) that are recommended by all international guidelines for stroke prevention in adults with atrial fibrillation (AF). Purpose To evaluate the safety and efficacy of DOACs in obese adults with AF. Methods Medline, CINAHL, Scopus, Web of Science, Cochrane Database, Johanna Briggs Institute, Embase, Psych Info and ProQuest were searched till April 2020. Only systematic reviews with meta-analyses, that were published after 2005 and were in the English language were included. Articles were screened by title and abstract, followed by full text assessment using the Covidence systematic review software. Data was extracted using a standardised extraction tool. AMSTAR-2® and ROBIS® tools were used for quality and risk of bias assessment. The entire process was undertaken by two investigators at each stage of the study selection, appraisal, and data extraction. Disagreements were resolved through consensus discussion with a third arbitrary investigator. Statistical analyses were performed using the DerSimonian and Laird method for random effects. Meta-analysis was performed using only randomised controlled trials from eligible systematic reviews at both 12 months and across the entire trial. Primary outcomes assessed was stroke (ischemic or haemorrhagic) or systemic or pulmonary embolism. Secondary outcomes assessed included all-cause mortality, transient ischemic attack, myocardial infarction, major bleed, all cause-hospitalisation, and cardiovascular mortality. Results Of the 8162 articles screened, a total of five systematic reviews were included in this overview. There was disagreement within the published reviews on the effect of DOAC in obesity. Four of the five reviews were of either “low” or “critically low” quality, with inconsistencies in data extraction and appropriateness of the included studies and statistical methods used in analysis. Data from only the RE-LY, AVERROES and ENGAGE AF-TIMI 48 trials, were available for the meta-analysis, which did not find any significant difference between all BMI groups for all outcomes, at both time points. However, analysis of the different weight groups versus normal weight, highlighted non-significant differences between the different DOACs. Conclusion There was no difference between the BMI classes in any of the outcomes assessed. However, the non-significant trends that were seen, suggests individual superiority of DOACs may exist within the obese adult populations. There is a need for prospective trials to evaluate which DOACs are safe and efficacious in the obese class III adults and at which dose. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Australian Government Research Training Program (RTP) Heart Foundation of AustraliaNational Health and Medical Research Council (NHMRC)

Two-year outcomes of patients with atrial fibrillation treated with rivaroxaban: results from RIVER registry

Abstract Introduction Non-vitamin-K oral anticoagulants (NOACs) were recommended in preference to oral vitamin K antagonists (VKAs) in the 2020 updated guidelines for stroke prevention in atrial fibrillation (AF), from the European Society of Cardiology (ESC). Rivaroxaban is a NOAC that is approved in many countries worldwide for reducing the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF). Purpose To explore the baseline characteristics, dosing and 2-year outcomes of patients with AF treated with rivaroxaban. Methods RIVaroxaban Evaluation in Real Life setting (RIVER) is a prospective international, multicenter registry of patients with newly diagnosed non-valvular AF treated with rivaroxaban for the prevention of thromboembolic stroke and at least one investigator-determined risk factor for stroke. Results A total of 5043 patients were enrolled into RIVER between January 2015 and June 2017. Mean (SD) age at diagnosis was 69.5 (11.0) years and 55.7% were males. Caucasian patients represented the largest proportion of patients in RIVER (80.3%), followed by Asians (5.5%) and hispanic/latino (3.7%). Almost all patients (98.5%) were prescribed a single daily dose of rivaroxaban, most commonly 20 mg (77.3%) and 15 mg (20.4%), while a 10 mg dose was prescribed in only 2.3% of patients. During the 2-year follow-up, the rates (95% CI) of all-cause mortality, stroke/SE, and major bleeding were 2.75 (2.43 to 3.12), 0.89 (0.72; 1.11), and 1.26 (1.05 to 1.52) per 100 person years, respectively (Figure 1). The most common cardiovascular cause of death was congestive heart failure (30.4%) and myocardial infarction (11.4%). Leading non-cardiovascular causes of death were malignancy (27.4%), respiratory failure (18.9%) and infections/sepsis (13.2%). Over 2 years, 710 (14.1%) of patients discontinued rivaroxaban. The corresponding proportions at 6 months and 1 year were 7.8% and 10.8%, respectively. Out of all the patients who discontinued, 62 (8.7%) restarted rivaroxaban during their follow-up (Table 1). Conclusion During 2 years of follow up in the international, prospective RIVER registry, rivaroxaban treatment for AF was associated with low rates of stroke or major bleeding. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by an unrestricted research grant from Bayer AG, Berlin, Germany, to TRI, London, UK. This work is supported by KANTOR CHARITABLE FOUNDATION for the Kantor-Kakkar Global Centre for Thrombosis Science.

2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement.

Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.