Survival Of Stroke Patients Research Articles

Long-term survival in stroke patients: insights into triglyceride-glucose body mass index from ICU data

BackgroundThe Triglyceride Glucose-Body Mass Index (TyG-BMI) has been established as a robust indicator of insulin resistance (IR), reflecting metabolic health across various populations. In general, lower TyG-BMI values are often associated with better metabolic health outcomes and a reduced risk of adverse health events in non-critically ill populations. Previous studies have highlighted a significant negative association between TyG-BMI and all-cause mortality (ACM) among critically ill atrial fibrillation patients. Given the high prevalence and severe outcomes associated with stroke, understanding how TyG-BMI at the time of ICU admission correlates with ACM in critically ill stroke patients becomes imperative. This study aims to assess the correlation between TyG-BMI and ACM in this specific patient cohort, exploring how traditional associations between TyG-BMI and metabolic health may differ in the context of acute, life-threatening illness.MethodsPatient data were retrieved by accessing the Medical Information Mart for Intensive Care IV (MIMIC-IV 2.2) database, categorizing patients into three groups on the basis of TyG-BMI tertiles. The study evaluated both primary and secondary outcomes: the primary outcomes included the 90-day, 180-day, and 1-year ACM, while secondary outcomes encompassed ICU, in-hospital, and 30-day ACM. Our study employed the Kaplan–Meier (K–M) curve method for outcome comparison across the groups while utilizing multivariate Cox proportional-hazards regression models and restricted cubic splines (RCS) to explore TyG-BMI association with these outcomes. Additionally, interaction and subgroup analyses were performed, focusing on different mortality time points.ResultsAmong a cohort of 1707 individuals diagnosed with stroke, the average age was 68 years (interquartile range [IQR]: 58–78 years), with 946 (55.42%) of the participants being male. The analysis of K-M curves suggested that patients having a lower TyG-BMI level faced a heightened risk of long-term ACM, whereas the short-term ACM exhibited no statistically significant differences across the three TyG-BMI groups. Furthermore, Cox proportional-hazards regression analysis validated a statistically significant increased risk of long-term ACM among patients belonging to the lowest TyG-BMI tertile. Additionally, RCS analysis results demonstrated L-shaped correlations between the TyG-BMI index and both short- and long-term ACM. These findings underscore the TyG-BMI predictive value for long-term mortality in stroke patients, highlighting a nuanced relationship that varies over different time frames. The results revealed no interactions between TyG-BMI and the stratified variables, with the exception of age.ConclusionIn our study, lower TyG-BMI levels in critically ill stroke patients are significantly related to a higher risk of long-term ACM within the context of the United States. This finding suggests the potential of TyG-BMI as a marker for stratifying long-term risk in this patient population. However, it's crucial to note that this association was not observed for short-term ACM, indicating that the utility of TyG-BMI may be more pronounced in long-term outcome prediction. Additionally, our conclusion that TyG-BMI could serve as a reliable indicator for managing and stratifying stroke patients over the long term is preliminary. To confirm our findings and assess the universal applicability of TyG-BMI as a prognostic tool, it is crucial to conduct rigorously designed research across various populations.

Abstract TMP113: RNA Sequencing Reveals Novel Pericytic MiR-15a/16-1 Targets in Post-Stroke Cerebral Angiogenesis

Introduction: Angiogenesis actively contributes to post-stroke functional recovery and improves long-term survival in stroke patients. Previously, we demonstrated that endothelium-targeted deletion of miR-15a/16-1 promotes post-stroke angiogenesis by enhancing classic pro-angiogenic factors and their receptors, and genetic deletion of miR-15a/16-1 in pericytes likewise promotes post-stroke functional recovery by stimulating cerebral angiogenesis. Here, we further investigate the underlying mechanisms and downstream targets of pericytic miR-15a/16-1 in cerebral angiogenesis after ischemic stroke. Methods: Pericyte-miR15a/16-1 conditional knockout mice (Pericyte-miR-15a/16-1 cKO) and wild-type (WT) controls were subjected to 1h MCAO followed by 7d reperfusion. Cerebral microvessels were extracted and subjected to RNA-seq to identify the significant differentially expressed genes (DEGs) that related to miR-15a/16-1 and angiogenesis among experimental groups. TargetScan and miRDB were used to predict potential miR-15a/16-1 downstream targets. Primary mouse brain vascular pericytes (mBVPs) were treated with lentivirus to achieve loss- or gain-of-miR-15a/16-1 function, and subjected to OGD 8h and reperfusion 24h. Pro-angiogenic factors were further verified by dual-luciferase reporter assay, qPCR, and western blotting. Results: RNA-seq analysis showed 289 upregulated genes (P < 0.05 & at least one CPM > 1) and 399 upregulated genes from 100 positive enriched gene sets (GESA) in cerebral microvessels of pericyte-miR-15a/16-1 cKO mice compared to WT controls 7d after MCAO. By comparing to miR-15a/16-1 potential target database from TargetScan and miRDB, 9 angiogenic genes were identified. Further biochemical analysis revealed that Pappa2, Fgf9, Islr, and Ccr2 mRNA and protein expression are significantly increased in cerebral microvessels of cKO mice and mBVPs with loss-of-miR-15a/16-1 function. Furthermore, dual-luciferase assay results verified that loss- or gain-of-miR-15a/16-1 function significantly increased or decreased luciferase reporter activity of these four genes, respectively. Conclusion: Our findings reveal novel pericytic miR-15a/16-1 mediated angiogenic targets in ischemic stroke.

Stroke survivors’ preferences for post-stroke self-management programs: A discrete choice experiment

Background and purposeSelf-management programs enhance survival in stroke patients. However, they require patient-centered designs to be effective. The aim of this study was therefore to investigate the type of post-stroke self-management programs that appeal to stroke survivors, and to estimate their willingness to participate in such programs. MethodsA Discrete Choice Experiment was administered to patients who had either a transient ischemic attack (TIA) or stroke within the past 3 years and were cognitively intact (i.e., stroke survivors). Stroke survivors were presented with eight choice tasks and asked to choose between ‘No Program’ and two hypothetical post-stroke management programs that varied by six attributes: Topics covered by the program; schedule of the program; frequency and duration of the sessions; number of participants; out-of-pocket registration fee for the whole program; and rewards for completing the program. ResultsThe analysis involved 146 stroke survivors. Based on the mixed logit model, the predicted willingness to participate ranged from 53% to 76%. The most popular characteristics in a program were topics on health education and risk management, being scheduled during weekends as four sessions that are each 2 hours long and involve four participants, a registration fee of SGD50 (∼USD36), and SGD500 (∼USD359) reward for program completion. ConclusionsInterest in post-stroke self-management programs was high, with at least half of the sample showing interest in participating in these programs. Program features such as focusing on health education and risk management, charging a low registration fee, and offering incentives helped to increase the demand.

Stroke survival and the impact of geographic proximity to family members: A population-based cohort study

IntroductionFamilial support may be important for post-stroke survival. ObjectiveTo determine if geographical proximity between stroke survivors and their family members, i.e having a spouse/partner or distance to a nearest first-degree relative (parents, siblings, and offspring), as a proxy for familial support, is related to survivor mortality. MethodsThis study included all stroke survivors (n=128,227) hospitalised in Norway from 1994 to 2009, who were 30 years or older at the time of the stroke (born before 1965). National registries and censuses were used to calculate the distance to the nearest first-degree relative in the hospitalisation year. Cox proportional hazards models estimated hazard ratios (HRs) of all-cause mortality from 1994 to 2014 (mean 6.4 years follow-up), adjusting for sociodemographic and clinical covariates. ResultsLiving up to 30 km from the nearest first-degree relative was associated with a higher mortality (HR 1.04, 95% CI: 1.03 to 1.06) than those living in the same household or neighbourhood as their nearest first-degree relatives. The association was more pronounced (1.13, 1.08 to 1.19 for ≤30 km; 1.25, 1.16 to 1.35 for >30 km) in survivors hospitalised at age ≤65 years, compared to older survivors. Among familial care predictors, having a spouse/partner was the most prominent predictor of reduced mortality (0.80, 0.78 to 0.82) in stroke survivors. ConclusionLiving close to first-degree relatives was weakly associated with better survival in stroke patients while having a spouse/partner exhibited a stronger association. Both associations were larger for survivors hospitalised at age ≤65 years. Our findings thus suggest that the impact of familial support on survival after stroke may differ by familial support condition and patient's age at a stroke hospitalisation.

Ambulation status at an acute care hospital predicts pneumonia and mortality in stroke patients: A retrospective cohort study.

Higher post-stroke functional performance is associated with lower mortality in patients with stroke. This study aimed to investigate the relationship between ambulation ability in the acute phase of stroke, and pneumonia and mortality 1year after stroke onset. This retrospective cohort study included consecutive stroke patients between April 2008 and December 2018. Patients were divided into six groups according to their Functional Ambulation Category score at discharge (0 [unable to walk] to 5 [able to walk independently]). We observed pneumonia cases and all-cause mortality over 1 year, and investigated the association between Functional Ambulation Category score and pneumonia or mortality. Survival analysis was carried out using Kaplan-Meier curves, log-rank tests and Cox regression models. We analyzed 1727 consecutive patients (median age 77 years; 54% men). During the observation period, 144 patients (8.3%) experienced pneumonia and 157 (9.1%) died. Increasing ambulatory impairment showed stepwise relationships with the risk of pneumonia and mortality. Compared with patients with a Functional Ambulation Category score of 5, those with scores of 4 and 3 showed no significant association with pneumonia risk; a score ≤2 was significantly different. There was a stepwise relationship between increased gait disturbance and risk of death compared with the Functional Ambulation Category 5 group. Ambulation ability at discharge from an acute hospital is an important predictor of pneumonia incidence and survival in stroke patients at 1 year; these associations were observed even after controlling for clinical parameters, such as stroke severity and comorbidity. Geriatr Gerontol Int 2022; 22: 554-559.

Predictors of death within 6 months of stroke onset: A model with Barthel index, platelet/lymphocyte ratio and serum albumin.

AimsTo develop and internally validate a nomogram to predict the risk of death within 6 months of onset of stroke in Chinese. Identifying risk factors with potentially direct effects on the nomogram will improve the quality of risk assessment and help nurses implement preventive measures based on patient‐specific risk factors.DesignA retrospective study.MethodsWe performed a least absolute shrinkage and selection operator (LASSO) regression modelling and multivariate logistic regression analysis to establish a prediction model of death risk in stroke patients within 6 months of onset. LASSO and time‐dependent Cox regression models were further used to analyse the 6‐month survival of stroke patients. Data were collected from 21 October 2013–6 May 2019.ResultsThe independent predictors of the nomogram were Barthel index (odds ratio (OR) = 0.980, 95% confidence interval (CI) = 0.961–0.998, p = .03), platelet/lymphocyte ratio (OR = 1.005, 95% CI = 1.000–1.010, p = .04) and serum albumin (OR = 0.854, 95% CI = 0.774–0.931, p < .01). This model showed good discrimination and consistency, and its discrimination evaluation C‐statistic was 0.879 in the training set and 0.891 in the internal validation set. The DCA indicated that the nomogram had a higher overall net benefit over most of the threshold probability range. The time‐dependent Cox regression model established the impact of the time effect of the age variable on survival time.ConclusionsOur results identified three predictors of death within 6 months of stroke in Chinese. These predictors can be used as risk assessment indicators to help caregivers performing clinical nursing work, and in clinical practice, it is suggested that nurses should evaluate the self‐care ability of stroke patients in detail. The constructed nomogram can help identify patients at high risk of death within 6 months, so that intervention can be performed as early as possible.

Association of blood pressure changes with survival after paramedic rapid sequence intubation in out-of-hospital patients with stroke.

Rapid sequence intubation (RSI) is used to secure the airway of some patients with stroke. Recent observational studies suggest that RSI is associated with poorer survival, and that decreases in systolic blood pressure (BP) following RSI could be a cause of worse survival. The present study aims to find if decreased systolic BP after paramedic RSI is associated with poorer survival in stroke patients transported by ambulance. The present study was a retrospective analysis of all stroke patients who received paramedic RSI attended by Ambulance Victoria, Australia. Logistic regression predicted the survival for strokes that had received RSI. The change in systolic BP during paramedic care was the main predictor. Of 43 831 patients with stroke, 882 (2%) received RSI. Almost 48% of RSI had a decline in systolic BP of more than 20% from baseline, and the decline in systolic BP after RSI was largest for intra-cerebral haemorrhage (-22.7 mmHg) compared to ischaemic strokes (-10.1 mmHg) or subarachnoid haemorrhage (-15.6 mmHg) (P = 0.001). Sixteen percent of the RSI group had an episode of hypotension anytime during the out-of-hospital care. For each 10 mmHg decrease in systolic BP with RSI for intra-cerebral haemorrhage an increase of 11% in the odds of survival is apparent (P = 0.04); for subarachnoid haemorrhage an increase of 17% (P = 0.02) and for ischaemic strokes a non-significant decrease of 7% (P = 0.26). Paramedic RSI-related decrease in systolic BP is associated with improved survival in those with intra-cerebral or subarachnoid haemorrhage but not ischaemic stroke.

Aplikasi Model Cox Proportional Hazard pada Pasien Stroke RSD Balung Kabupaten Jember

&lt;p&gt;According to the World Health Organization (WHO) cardiovascular disease is a disease caused by impaired heart and blood vessel function. There are many types of cardiovascular disease, but the most common and most well-known are coronary heart disease and stroke. Stroke is a syndrome characterized by symptoms and / or rapidly developing clinical signs in the form of focal and global brain functional disorders lasting more than 24 hours (unless there are surgical interventions or bringing death), which are not caused by other causes besides vascular causes. The number of stroke patients in Indonesia in 2013 based on the diagnosis of health personnel (Nakes) was 1.236.825 (7,0%), while based on the diagnosis of symptoms was 2.137.941 (12,1%). In this study the factors that can affect the survival of stroke sufferers were analyzed using the Cox proportional hazard regression model, the dependent variable was the length of time the patient was treated and the independent variables were gender, age, hypertension status, cholesterol status, Diabetes Militus (DM) status, stroke type, and Body Mass Index (BMI). The result showed that age, DM status, and type of stroke were the most influential factors on the survival of stroke patients at Balung Regional Hospital.&lt;/p&gt;&lt;strong&gt;Keywords : &lt;/strong&gt;stroke disease, survival analysis, Cox proportional hazard model

Time Trends and Monthly Variation in Swedish Acute Stroke Care.

Background and Purpose: Studies of monthly variation in acute stroke care have led to conflicting results. Our objective was to study monthly variation and longitudinal trends in quality of care and patient survival following acute stroke.Methods: Our nationwide study included all adult patients (≥18 years) with acute stroke (ischemic or hemorrhagic), admitted to Swedish hospitals from 2011 to 2016, and that were registered in The Swedish Stroke Register (Riksstroke). We studied how month of admission and longitudinal trends affected acute stroke care and survival. We also studied resilience to this variation among hospitals with different levels of specialization.Results: We included 132,744 stroke admissions. The 90-day survival was highest in May and lowest in January (84.1 vs. 81.5%). Thrombolysis rates and door-to-needle time within 30 min increased from 2011 to 2016 (respectively, 7.3 vs. 12.8% and 7.7 vs. 28.7%). Admission to a stroke unit as first destination of hospital care was lowest in January and highest in June (78.3 vs. 80.5%). Stroke unit admission rates decreased in university hospitals from 2011 to 2016 (83.4 vs. 73.9%), while no such trend were observed in less specialized hospitals. All the differences above remained significant (p < 0.05) after adjustment for possible confounding factors.Conclusion: We found that month of admission and longitudinal trends both affect quality of care and survival of stroke patients in Sweden, and that the effects differ between hospital types. The observed variation suggests an opportunity to improve stroke care in Sweden. Future studies ought to focus on identifying the specific factors driving this variation, for subsequent targeting by quality improvement efforts.

Association between continuity of care and long-term mortality in Taiwanese first-ever stroke survivors: An 8-year cohort study.

BackgroundContinuity of care is considered to be an important principle of stroke care; however, few analyses of empirically related outcomes have been reported.ObjectiveThis study examined the correlation between the continuity of care for outpatients after a stroke event and the survival of stroke patients over the year following hospital discharge.Research designData from the Taiwan National Health Insurance Database were used in this study. We defined stroke as the ICD-9-CM codes 430 to 437, and all patients were followed up regarding their survival for at least one year. The modified modified continuity index (MMCI) was used as the indicator of continuity of care. Cox proportional hazard models with robust sandwich variance estimates were employed to analyze the correlation between continuity of care and stroke-related death.ResultsA total of 9,252 stroke patients were included in the analysis. Those patients who had a high and a completed COC had a higher percentage of survival (97.25% and 95.39%) compared to the other two groups. After controlling for other variables, compared with the low-level continuity of care group, the moderate-level, high-level and completed continuity of care groups still showed a significantly lower risk of death HR (95% CI) were: 0.63 (0.49–0.80), 0.56 (0.40–0.79) and 0.50 (0.39–0.63), respectively.ConclusionContinuity of care may increase the survival among stroke patients and therefore plays an important role in management of stroke after survival.

Upper limb spasticity surgery in adults: What we learned in 5 years of practicing it

We have been practicing surgical management of adult upper limb spasticity for the past 5 years. So far, we have evaluated 20 patients, and we have operated on nine patients with spasticity of the upper limb in Cyprus and the United Kingdom. We aim to present the setup and running of a new service, which is devoted to Surgery for Spasticity of the Upper Limb. We present our structure, organisational processes and service provision as well as our results in the nine cases that had surgical treatment as a part of their management (as well as our preferred techniques). We discuss our outcomes as well as our learning points from these cases. We also believe that selective neurectomy procedures can be very useful in the surgical management of upper limb spasticity. Tendon transfers to augment finger extension have a limited role and provide no significant benefits in adult spasticity cases. In addition, we found that the extensor carpi ulnaris transfer to extensor carpi radialis brevis has in our experience, reliable results regarding concentric wrist extension as well as easier rehabilitation. Furthermore, in severe cases, where no functional improvement is expected, joint fusions have a more predictable outcome. Spasticity reduction surgery does gain ground with the increase in survival of stroke patients as well as traumatic brain injury patients. Therefore, up to date methods for assessing, operating and evaluating postoperatively this category of patients need to be vigorously checked.

Abstract WP192: Last Known Well to Arrival Times in Midwest Hospitals Indicate Need for Further Community Education

Background &amp; Objectives: Timely administration of IV Alteplase in ischemic stroke patients can lead to reduction in the severity of disability and improve patient outcomes. The treatment window for IV Alteplase is within 3 hours of last known well (LKW) and up to 4.5 hours in certain eligible patients. Community education of the message “time is brain” is a critical component in the chain of survival for stroke patients. The American Heart Association and the American Stroke Association have focused community awareness efforts on signs &amp; symptoms recognition and the importance of acting F.A.S.T. © when stroke symptoms occur. Our objective is to determine if ischemic stroke patients are arriving to the hospital within the timeframe to be eligible for IV Alteplase treatment. Methods: Get With the Guidelines (GWTG) -Stroke® is a quality improvement initiative to improve care by promoting adherence to scientific guidelines. A retrospective review was conducted of 337, 407 ischemic stroke patients from over 325 hospitals using GWTG-Stroke® in the Midwest from 2011 through 2016. LKW to hospital arrival times were analyzed. Results: The percentage of patients arriving within 3 hours of LKW was as follows: 23.3% in 2011, 22.5% in 2012, 23.1% in 2013, 22.5% in 2014, 23.4% in 2015, and 23.3% in 2016. The percentage of patients arriving within 4.5 hours of LKW: 29.1% in 2011, 28.2 % in 2012, 28.9% in 2013, 28.4% in 2014, 29.5% in 2015, 29.4% in 2016. Conclusions: Throughout the six years of this study, an average of only 23% of ischemic stroke patients arrived to the hospital within 3 hours of LKW, with slightly more, 29%, of patients arriving within the extended window (4.5 hrs of LKW) to be considered eligible for IV Alteplase treatment. With greater than 70% of patients arriving too late to receive this clot-busting drug, this data identifies the continued need for community education regarding acting F.A.S.T. © in recognizing signs and symptoms of stroke.

Abstract W P315: Outcomes Of In-hospital Cardiopulmonary Resuscitation In Stroke Patients Admitted In The United States, Years 2005-2011

Background: There is no recent study on the outcomes of cardiopulmonary resuscitation (CPR) in stroke patients. We wanted to analyze the outcomes of in-hospital CPR in these patients in comparison with the general population without stroke. Methods: Data from all patients admitted to US hospitals between 2005 and 2011 were analyzed. We used the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) primary or secondary procedure codes 99.60 to identify the adult patients (≥18years) who underwent cardiopulmonary resuscitation. Patients who had cardiopulmonary arrest (427.50) as a primary admission diagnosis were excluded to avoid including patients who experienced an out-of hospital event in our analysis. The effect of stroke on discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Yearly national trends in survival in stroke patients were examined using the Cochran-Armitage trend test. Results: Of 648,168 patients who underwent CPR, 43753 (6.8%) were admitted withstroke. Strokeatients who underwent CPR had higher rates of discharge to nursing facility (18.4% versus 14.0% p=&lt;0.0001) but no difference was noted in in-hospital mortality (74.1% versus 74.2% p= 0.9) compared to those without stroke. After adjusting for potential confounders, CPR in patients with stroke had higher odds of discharge to nursing facility [odds ratio (OR) 1.8, 95% confidence interval (CI) (1.6-2.0, p= &lt;.0001)] and death [(OR) 1.11, 95% (CI) (1.06-1.14, p=0.05)]. Survival in stroke patients undergoing CPR improved in 2011 (19 % in the year 2011 vs. 11 % in the year 2005; p=&lt;.0001) as compared with the previous years. Conclusion: CPR in stroke patients is associated with significantly higher rates of disability at discharge. Survival appears to be improving over the last 6 years in these patients.

Assessing improvements in survival for stroke patients in the Northern Territory 1992-2013: a marginal structural analysis.

The aim of the present study was to investigate changes in stroke survival among Indigenous and non-Indigenous patients in the Northern Territory (NT). A longitudinal study was undertaken of stroke patients admitted to NT public hospitals between 1992 and 2013. The Kaplan-Meier method and proportional hazards regression were used for survival analysis. A marginal structural model was applied to adjust for time-dependent confounders and informative censoring. RESULTS; There were 4754 stroke in-patients over the period, with 3540 new cases and 837 stroke deaths. Mean age of onset for Indigenous patients (51.7 years) was 12.3 years younger than that for non-Indigenous patients. After adjustments for confounders and loss to follow-up, in-hospital deaths were more likely among Indigenous patients (hazard ratio (HR) = 1.56; P < 0.01) and less likely among males (HR = 0.86; P < 0.05) and patients from remote areas (HR = 0.72; P < 0.01). There was a 3% decrease annually in mortality hazard from 1992 to 2013. Renal disease, cancer and chronic obstructive pulmonary disease had deleterious effects on stroke survival. Stroke survival has improved in the NT over the past two decades. The marginal structural models provide a powerful methodological tool that can be applied to hospital administrative data to assess changes in quality of care and the impact of interventions.

Association between Serum Concentration of Vitamin D and 1-Year Mortality in Stroke Patients

Background: The prevalence of 25-hydroxyvitamin D [25(OH)D] deficiency is high in patients presenting with an acute stroke, and it may be associated with greater clinical severity and a poor early functional prognosis. However, no data about its impact on long-term prognosis is available. In this study, we aimed to assess the association between 25(OH)D levels and 1-year mortality in stroke patients. Methods: From February to December 2010, 382 Caucasian stroke patients admitted to the Department of Neurology of the University Hospital of Dijon, France, were enrolled prospectively. Demographics and clinical information including stroke severity assessed using the National Institutes of Health Stroke Scale score were collected. The serum concentration of 25(OH)D was measured at baseline. Multivariable Cox regression models were used to evaluate the association between 1-year all-cause mortality and serum 25(OH)D levels treated as either a log-transformed continuous variable or dichotomized (<25.7 and ≥25.7 nmol/l) at the first tertile of their distribution. Results: Of the 382 stroke patients included, 63 (16.5%) had died at 1 year. The mean 25(OH)D level was lower in these patients (32.3 ± 22.0 vs. 44.6 ± 28.7 nmol/l, p < 0.001), and survival at 1 year was worse in patients in the lowest tertile of 25(OH)D levels (defined as <25.7 nmol/l); log-transformed 25(OH)D levels were inversely associated with 1-year mortality (hazard ratio, HR = 0.62; 95% confidence interval, 95% CI: 0.44-0.87; p = 0.007), and patients with 25(OH)D levels <25.7 nmol/l were at a higher risk of death at 1 year (HR = 1.95; 95% CI: 1.14-3.32; p = 0.014). In multivariable analyses, the association was no longer significant but a significant interaction was found for age, and stratified analyses by age groups showed an inverse relationship between 25(OH)D levels and 1-year mortality in patients aged <75 years [HR = 0.38; 95% CI: 0.17-0.83; p = 0.015 for log-transformed 25(OH)D levels, and HR = 3.12; 95% CI: 0.98-9.93; p = 0.054 for 25(OH)D levels <25.7 vs. >25.7 nmol/l]. Conclusion: A low serum 25(OH)D level at stroke onset may be associated with higher mortality at 1 year in patients <75 years old. Further studies are needed to confirm these findings and to determine whether vitamin D supplementation could improve survival in stroke patients.

Reverse epidemiology in ischemic stroke: high cholesterol as a predictor of improved survival in stroke patients

Evaluation of: Markaki I, Nilsson U, Kostulas K, Sjostrand C. High cholesterol levels are associated with improved long-term survival after acute ischemic stroke. J. Stroke Cerebrovasc. Dis. 23(1), e47–e53 (2014). Although high serum cholesterol concentration is a well-known risk factor of atherosclerosis, which is one of the major causes of ischemic cerebral stroke, some studies suggested that low cholesterol levels are associated with poor outcome in patients after stroke. In the evaluated study, the relationship between cholesterol level measured on admission to the hospital in patients with ischemic stroke and long-term mortality was evaluated. It was demonstrated that total serum cholesterol concentration higher than 4.6 mM was an independent predictor of lower mortality within the observation period (median: 30 months). These results suggest the 'reverse epidemiology' phenomenon, with regard to serum cholesterol, in acute stroke survivors.

Abstract W P315: Cardio-Respiratory Arrest in Stroke (CAIS Study): Predisposing Factors, Clinical Features, Outcomes, and Process Measures

Objectives: Limited information is available on the prevalence of cardiorespiratory arrest (CA) and its predisposing factors in patients with acute ischemic stroke. We analyzed/evaluated clinical characteristics, risk factors, access to care, and survival in stroke patients who developed a cardiac arrest. Methods: This is a multicenter cohort study including consecutive patients with acute ischemic stroke admitted to regional stroke centers participating in the Registry of the Canadian Stroke Network from July 2003 to March 2008. Patients with DNR order on admission were excluded. CA was defined as cardiac or respiratory arrest within 30 days of admission documented by a physician and identified from resuscitation records. The main outcome measures were the 30-day and 1-year survival among patients with CA vs. no CA. We also assessed the association between medical complications during hospitalization and CA. Results: Overall, 9,019 patients with acute ischemic stroke were included. Cardiac arrest was observed in 352 patients (3.9%). In patients with CA, 30-day survival (17.9% vs. 90.7%, P&lt;0.001) and 1-year survival (4.5% vs. 80.1, p&lt;0.001) were significantly lower. Less than 1% of stroke patients with CA were discharged home (vs. 47.3%; p&lt;0.0001). Other outcome measures are summarized in Table 1. On multivariable analyses, older age, more severe stroke, previous history of myocardial infarction, congestive heart failure, atrial fibrillation, and diabetes were associated with CA. Conclusions: Cardiac arrest affects less than 5% of patients admitted with an acute ischemic stroke and is associated with poor outcomes. Less than 1% of patients were independent or discharged home.

Abstract T P333: Impact of Secondary Prevention Therapy on Mortality after a First Ischemic Stroke in Puerto Rico

Background: Stroke is the fourth leading cause of death and the most prevalent cause of long-term disability in Puerto Rico. Prompt implementation of evidence-based clinical practice guidelines by physicians is crucial to reduce morbidity and mortality in patients with a first ischemic stroke. Purpose: The purpose of this study is to evaluate the impact of prescription of secondary prevention therapies on mortality in Puerto Rican patients hospitalized with a first ischemic stroke. Methods: This was a retrospective secondary data analysis of 2007 and 2009 Puerto Rico Stroke Registry electronic database. Information was obtained from the medical charts of patients discharged with ICD-9 codes 434 and 436 from 20 hospitals located in Puerto Rico. Descriptive analyses were conducted for demographics and comorbidities. Chi2 statistics compared the proportion of patients prescribed secondary prevention therapy and the proportion of patients not prescribed secondary prevention therapy. Lastly, survival rates were calculated to December 2010. Results: The mean age of 3,965 patients was 70 years (+/-13.8) and 64% were females older than 84 years. The most frequent comorbidities were hypertension (85%), diabetes (52%), and hyperlipidemia (25%). Secondary prevention therapy was prescribed to 11% of the patients. The case-fatality-rate for patients prescribed secondary prevention therapy was 16% compared to 26% for patients not prescribed secondary prevention therapy (P&lt; 0.01). The mean survival for stroke patients prescribed secondary preventions was 450 days, (95% CI,182-718) compared to 266 days, (95% CI, 244-287) for those not prescribed secondary prevention therapy (p= 0.175). Conclusion: A low percentage of patients with first ischemic stroke were prescribed secondary prevention therapy. Although our findings suggest that secondary prevention therapy decreased mortality in patients with stroke, the difference did not reach statistical significance.

Survival of stroke patients after introduction of the ‘Dutch Transmural Protocol TIA/CVA’

BackgroundEarlier research showed that healthcare in stroke could be better organized, aiming for improved survival and less comorbidity. Therefore, in 2004 the Dutch College of General Practitioners (NHG) and the Dutch Association of Neurology (NVN) introduced the ‘Dutch Transmural Protocol TIA/CVA’ (the LTA) to improve survival, minimize the risk of stroke recurrence, and increase quality of life after stroke. This study examines whether survival improved after implementation of the new protocol, and whether there was an increase in contacts with the general practitioner (GP)/nurse practitioner, registration of comorbidity and prescription of medication.MethodsFrom the primary care database of the Registration Network Groningen (RNG) two cohorts were composed: one cohort compiled before and one after introduction of the LTA. Cohort 1 (n = 131, first stroke 2001–2002) was compared with cohort 2 (n = 132, first stroke 2005–2006) with regard to survival and the secondary outcomes.ResultsComparison of the two cohorts showed no significant improvement in survival. In cohort 2, the number of contacts with the GP was significantly lower and with the nurse practitioner significantly higher, compared with cohort 1. All risk factors for stroke were more prevalent in cohort 2, but were only significant for hypercholesterolemia. In both cohorts more medication was prescribed after stroke, whereas ACE inhibitors were prescribed more frequently only in cohort 2.ConclusionNo major changes in survival and secondary outcomes were apparent after introduction of the LTA. Although, there was a small improvement in secondary prevention, this study shows that optimal treatment after introduction of the LTA has not yet been achieved.

Prognostic Value of a Single Prehospital Measurement of N-Terminal Pro-Brain Natriuretic Peptide and Troponin T after Acute Ischaemic Stroke

Data regarding the value of prehospital measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T as prognostic indicators of in-hospital mortality are limited. This prospective pilot study aimed to determine the value of a single combined measurement of NT-proBNP and troponin T for predicting in-hospital mortality in patients with acute ischaemic stroke in a prehospital emergency medicine centre. Blood samples were collected in the prehospital setting and analysed for NT-proBNP and troponin T, using a portable device. Parameters previously associated with stroke severity (including prognostic scoring systems) were recorded and assessed as independent predictors of in-hospital mortality. In logistic regression analysis, elevated troponin T (odds ratio [OR] 1.8 [95% CI 1.1, 8.4) and elevated NT-proBNP (OR 5.80 [95% CI 1.3, 22.7]) were significantly associated with poor outcome in patients with acute ischaemic stroke. Combined measurement of troponin T plus NT-proBNP was most predictive of survival in stroke patients (93% sensitivity, 96% specificity, 80% negative predictive value, 98% positive predictive value and 92% area under the receiver operating curve). NT-proBNP and troponin T levels, measured during the prehospital phase of care after acute ischaemic stroke, are strong predictors of in-hospital mortality.