Terms Of Ischemic Stroke Research Articles

Comparison of Non-Vitamin K Antagonist Oral Anticoagulants on Ischemic Stroke and Bleeding

Objective: Non-vitamin K antagonist oral anticoagulants (NOACs) have become widely utilized for various clinical indications, including non-valvular atrial fibrillation (NVAF), deep vein thrombosis (DVT), and apical thrombus. Despite their increasing popularity, limited comparative data exist on the clinical outcomes associated with different NOACs. This study aims to address this gap by directly comparing NOACs in terms of ischemic stroke, hemorrhagic stroke, and gastrointestinal bleeding. Materials and Methods: A retrospective search of the electronic database was conducted to identify patients using NOACs for NVAF, DVT, and apical thrombus. Clinical outcomes, including ischemic stroke, hemorrhagic stroke, and gastrointestinal bleeding, were directly compared among different NOACs. The chi-square test and Fisher's exact test were employed to assess the relative incidence of stroke and extracranial complications across four patient groups. Results: Among the 4,112 retrospectively analyzed patients, 55 were included in the study. Demographic and clinical profiles showed no significant differences among patients in the four different drug groups (p > 0.05). Ischemic stroke was observed in 90.9% of the patients, hemorrhagic stroke in 5.8%, and gastrointestinal bleeding in 3.3%. A statistically significant difference was identified between drug doses and the rate of ischemic stroke (p < 0.001). Conclusion: The findings of this retrospective study carry significant implications, especially considering the widespread global use of NOACs. The study revealed no discernible difference in the risk of ischemic stroke among patients using different NOACs. Notably, the risk of hemorrhagic stroke was dose-dependent in the dabigatran group, while rivaroxaban was associated with the highest risk of gastrointestinal bleeding. Given the elevated rate of thromboembolism in patients and the relatively short half-life of NOACs, the study concludes that further optimization of NOAC use is imperative.

Short-term outcomes of catheter ablation in atrial fibrillation in patients with metabolic syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Metabolic syndrome is widely discussed lately and it is consists of several components, which in turns exaggerates the development of the cardiovascular disease and rhythm disorders. Atrial fibrillation (AF) is considered one of the common type of heart rhythm disorders. Effects of metabolic syndrome components on outcomes of catheter ablation in AF remain poorly understood. Purpose Assess the influence of metabolic syndrome and its components on short-term outcomes of catheter ablation on atrial fibrillation. Methods We carried out a retrospective analysis of 120 patients who underwent atrial fibrillation ablation for the first time. 60 out of them were diagnosed with concomitant MetS (Group I) whereas 60 without MetS (Group II). Clinical outcomes, cardiovascular and all caused hospitalizations, procedural complications, AF recurrence, ischemic stroke were assessed. All endpoints were assessed at least 12 months after the catheter ablation. Results Median CHA2DS2-VASc were higher in Group I than Group II (2.2 (1-4) vs. 1.9 (1-3), P<0.05). Patients with MetS tended to have larger median diameter of left atrial than those without it (4.3 vs. 4.0, P<0.05). Cardiovascular and all cause hospitalizations did not differ in two groups (P>0.05). Median total radiofrequency duration (59.0 min vs. 61 min, P>0.05) and procedural complications (P>0.05) did not significantly differ between groups. AF recurrence in 12 months tended to be higher in Group I than Group II (9.0 vs.5.0, P>0.05). There were not statistically significant changes between groups in terms of ischemic stroke (1.0 vs. 1.0, P>0.05). Using multivariate regression analysis, among MetS components abdominal obesity (1.7 (1.1-2.1), P<0.05) hypertension (1.5 (1.1-1.9), P<0.05) were positively correlated with AF recurrence whilst median left atrial diameter was only correlated with hypertension (1.6 (1.1-2.0), P<0.05) after adjusting other risk factors. Conclusion AF recurrence in short-term period of catheter ablation in AF higher in patients with MetS. Further studies with large amount of patients are required along with assessment in long-term period.

Neuroprotective Effects of Resveratrol in Ischemic Brain Injury

Cerebral ischemia represents the third cause of death and the first cause of disability in adults. This process results from decreasing cerebral blood flow levels as a result of the occlusion of a major cerebral artery. This restriction in blood supply generates low levels of oxygen and glucose, which leads to a decrease in the energy metabolism of the cell, producing inflammation, and finally, neurological deterioration. Currently, blood restoration of flow is the only effective approach as a therapy in terms of ischemic stroke. However, a significant number of patients still have a poor prognosis, probably owing to the increase in the generation of reactive oxygen species (ROS) during the reperfusion of damaged tissue. Oxidative stress and inflammation can be avoided by modulating mitochondrial function and have been identified as potential targets for the treatment of cerebral ischemia. In recent years, the beneficial actions of flavonoids and polyphenols against cerebrovascular diseases have been extensively investigated. The use of resveratrol (RSV) has been shown to markedly decrease brain damage caused by ischemia in numerous studies. According to in vitro and in vivo experiments, there is growing evidence that RSV is involved in several pathways, including cAMP/AMPK/SIRT1 regulation, JAK/ERK/STAT signaling pathway modulation, TLR4 signal transduction regulation, gut/brain axis modulation, GLUT3 up-regulation inhibition, neuronal autophagy activation, and de novo SUR1 expression inhibition. In this review, we summarize the recent outcomes based on the neuroprotective effect of RSV itself and RSV-loaded nanoparticles in vitro and in vivo models focusing on such mechanisms of action as well as describing the potential therapeutic strategies in which RSV plays an active role in cases of ischemic brain injury.

Comparison of Left Atrial Appendage Occlusion versus Non-Vitamin-K Antagonist Oral Anticoagulation in High-Risk Atrial Fibrillation: An Update.

Transcatheter left atrial appendage occlusion (LAAO) is non-inferior to vitamin K antagonists (VKAs) in preventing thromboembolic events in atrial fibrillation (AF). Non-vitamin K antagonists (NOACs) have an improved safety profile over VKAs; however, evidence regarding their effect on cardiovascular and neurological outcomes relative to LAAO is limited. Up-to-date randomized trials or propensity-score-matched data comparing LAAO vs. NOACs in high-risk patients with AF were pooled in our study. A total of 2849 AF patients (LAAO: 1368, NOACs: 1481, mean age: 75 ± 7.5 yrs, 63.5% male) were enrolled. The mean CHA2DS2-VASc score was 4.3 ± 1.7, and the mean HAS-BLED score was 3.4 ± 1.2. The baseline characteristics were comparable between the two groups. In the LAAO group, the success rate of device implantation was 98.8%. During a mean follow-up of 2 years, as compared with NOACs, LAAO was associated with a significant reduction of ISTH major bleeding (p = 0.0002). There were no significant differences in terms of ischemic stroke (p = 0.61), ischemic stroke/thromboembolism (p = 0.63), ISTH major and clinically relevant minor bleeding (p = 0.73), cardiovascular death (p = 0.63), and all-cause mortality (p = 0.71). There was a trend toward reduction of combined major cardiovascular and neurological endpoints in the LAAO group (OR: 0.84, 95% CI: 0.64–1.11, p = 0.12). In conclusion, for high-risk AF patients, LAAO is associated with a significant reduction of ISTH major bleeding without increased ischemic events, as compared to “contemporary NOACs”. The present data show the superior role of LAAO over NOACs among high-risk AF patients in terms of reduction of major bleeding; however, more randomized controlled trials are warranted.

COVID-19, thromboembolic risk, and Virchow's triad: Lesson from the past.

COronavirus Infectious Disease which started in 2019 (COVID‐19) usually presents with the signs and symptoms of pneumonia. However, a growing number of recent reports highlight the fact that the infection may be by far more than only a respiratory disease. There is evidence of an increased thromboembolic risk in COVID‐19 patients, with a variety of manifestations in terms of ischemic stroke, deep vein thrombosis, acute pulmonary embolism, acute myocardial infarction, systemic arterial embolism, and placental thrombosis. The German physician Rudolph Virchow, about two centuries ago, described three pivotal factors contributing together to thromboembolic risk: endothelial injury, hypercoagulability, and blood stasis. COVID‐19‐associated hypercoagulability is unique and distinctive, and has its own features involving the immune system. Many of the drugs proposed and currently undergoing evaluation for the treatment of COVID‐19 have one or more of the Virchow's triad elements as a target. The three factors outlined by Virchow are still able to explain the venous and arterial hypercoagulable state in the dramatic COVID‐19 setting. Nowadays, we have decidedly more sophisticated diagnostic tools than Virchow had, but many of the challenges that we are facing are the same as Virchow faced in the 19th century.

Meta-Analysis Evaluating Outcomes of Surgical Left Atrial Appendage Occlusion During Cardiac Surgery

Surgical left atrial appendage occlusion (S-LAAO) has become a common procedure performed in patients undergoing cardiac surgery; however, evidence to support this procedure remains inconclusive. This meta-analysis aims to assess the efficacy of S-LAAO in terms of ischemic stroke, postoperative atrial fibrillation, and all-cause mortality. A thorough literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We identified 10 relevant studies for our meta-analysis. It included 6,779 patients who underwent S-LAAO and 6,573 who did not undergo LAAO. In terms of ischemic stroke, the S-LAAO cohort had a lower events (pooled odds ratio [OR] 0.655 (0.518 to 0.829), p = 0.0004) compared with the non-LAAO cohort. S-LAAO cohort also had lower events of all-cause mortality (pooled OR 0.74 (95% confidence interval 0.55 to 0.99), p = 0.0408) when compared with the non-LAAO cohort. In regards to postoperative atrial fibrillation, there was no difference between the 2 groups (pooled OR 1.29 (95% confidence interval 0.81 to 2.06), p = 0.2752). In conclusion, S-LAAO was associated with lower events of ischemic stroke or systemic embolism and all-cause mortality when compared to the non-LAAO group.

Meta-analysis of real-world evidence comparing non-vitamin K antagonist oral anticoagulants with vitamin K antagonists for the treatment of patients with non-valvular atrial fibrillation

ABSTRACTIntroduction: Numerous real-world studies have compared non-vitamin K antagonist oral anticoagulants (NOACs) with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF). A meta-analysis was performed to synthesize the available evidence.Methods: Systematic searches were performed through 12/2016 to identify non-randomized NVAF studies comparing NOACs with VKAs, and reporting effectiveness, safety, or persistence.Results: Of 562 citations identified, 49, 79, and 18 compared rivaroxaban, dabigatran, and apixaban, respectively, with VKAs and were included. Compared with VKAs, rivaroxaban was associated with a reduced risk of ischemic stroke (IS) (hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.75–0.93), intracranial haemorrhage (ICH) (HR = 0.69, 95% CI = 0.52–0.90), and non-persistence (HR = 0.62, 95% CI = 0.60–0.65). Dabigatran was associated with a significantly lower risk of IS (HR = 0.80, 95% CI = 0.65–0.98) and ICH (HR = 0.45, 95% CI = 0.36–0.58), but not for non-persistence (HR = 0.91, 95% CI = 0.53–1.55), compared with VKAs. Apixaban was associated with a lower risk of ICH than VKAs (HR = 0.41, 95% CI = 0.28–0.60), but was not different to VKAs in terms of IS (HR = 1.01, 95% CI = 0.87–1.17) or non-persistence (HR = 1.08, 95% CI = 0.81–1.45).Conclusion: NOACs appear to be at least as effective and safe as VKAs for stroke prevention in patients with NVAF.

Poor outcomes associated with antithrombotic undertreatment in patients with atrial fibrillation attending Gondar University Hospital: a retrospective cohort study

BackgroundAtrial fibrillation (AF) is a major risk factor for stroke as it increases the incidence of stroke nearly fivefold. Antithrombotic treatment is recommended for the prevention of stroke in AF patients. However, majorly due to fear of risk of bleeding, adherence to recommendations is not observed. The aim of this study was to investigate the impact of antithrombotic undertreatment, on ischemic stroke and/or all-cause mortality in patients with AF.MethodsA retrospective cohort study was conducted from January 7, 2017 to April 30 2017 using medical records of patients with AF attending Gondar University Hospital (GUH) between November 2012 and September 2016. Patients receiving appropriate antithrombotic management and those on undertreatment, were followed for development of ischemic stroke and/or all-cause mortality. Kaplan-Meier and a log-rank test was used to plot the survival analysis curve. Cox regression was used to determine the predictors of guideline-adherent antithrombotic therapy.ResultsThe final analysis included 159 AF patients with a median age of 60 years. Of these, nearly two third (64.78%) of patients were receiving undertreatment for antithrombotic medications. Upon multivariate analysis, history of ischemic stroke/transient ischemic attack (TIA) was associated with lower incidence of antithrombotic undertreatment. A significant increase (HR: 8.194, 95% CI: 2.911–23.066)] in the incidence of ischemic stroke and/or all-cause mortality was observed in patients with undertreatment. Up-on multivariate analysis, only increased age was associated with a statistically significant increase incidence of ischemic stroke and/or all-cause mortality, while only history of ischemic stroke/TIA was associated with a decrease in the risk of ischemic stroke and/or all-cause mortality.ConclusionAdherence to antithrombotic guideline recommendations was found to be crucial in reducing the incidence of ischemic stroke and/or all-cause mortality in patients with AF without increasing the risk of bleeding. However, undertreatment to antithrombotic medications was found to be high (64.78%) and was associated with poorer outcomes in terms of ischemic stroke and/or all-cause mortality. Impact on practice: This research highlighted the magnitude of antithrombotic undertreatment and its impact on ischemic stroke and/or all-cause mortality in patients with AF. This article has to alert prescribers to routinely evaluate AF patients’ risk for ischemic stroke and provide appropriate interventions based on guideline recommendations.

Hospitalized frail elderly patients - atrial fibrillation, anticoagulation and 12 months' outcomes.

Background and objectiveMultiple chronic conditions and recurring acute illness are frequent among elderly people. One such condition is atrial fibrillation (AF), which increases the risk of stroke up to fivefold. The aim of this study was to investigate the prevalence of AF among hospitalized frail elderly patients, their use of anticoagulation and their 12-month outcomes.Patients and methodsThis was a clinical observational study of acutely hospitalized frail patients over the age of 75 years. The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF. Clinically relevant outcomes were the composite of ischemic stroke and/or bleeding within 12 months, which was considered as primary in the analysis, ischemic stroke/transient ischemic attack (TIA), mortality, bleeding and hospital care consumption. Student’s t-test, Fisher’s exact test, Mann–Whitney U test and a Cox proportional hazards model were used for the analyses.ResultsThe prevalence of AF was 47%, and 63% of them were prescribed an anticoagulant. AF patients without anticoagulation were older, more often females, more often in residential care, and they had worse Mini Nutritional Assessment and activities of daily living scores. Of the patients without anticoagulation, 56% had a documented contraindication. In univariate analysis, there were significantly more events among AF patients without anticoagulation regarding the composite outcome of ischemic stroke and/or bleeding (hazard ratio [HR] 3.65, 95% CI = 1.70–7.86; p < 0.001). When adjusting for potential confounders in Cox regression analysis, the difference remained significant (HR 4.54, 95% CI = 1.83–11.25; p = 0.001).ConclusionThe prevalence of AF in a hospitalized frail elderly population was 47%. Of these, 63% were prescribed anticoagulation therapy. Almost half of the patients without stroke prophylaxis had no documented contraindication. At 1 year, there were significantly more events in terms of ischemic stroke and/or bleeding among AF patients without anticoagulation therapy than among those with.

The Efficacy and Safety of 3 Types of Interventions for Stroke Prevention in Patients With Cardiovascular and Cerebrovascular Diseases: A Network Meta-analysis

PurposeThe goal of this study was to compare the relative efficacy and safety of different types of interventions for stroke prevention in patients with cardiovascular and cerebrovascular diseases. MethodsThis network meta-analysis (NMA) was conducted with a random effects model of Bayesian framework using Stata version 12.0. Odds ratios (ORs) and their credible intervals (CrIs) were applied for the efficacy and safety evaluation of various medical interventions, including aspirin, dipyridamole, ticlopidine, warfarin, and apixaban. In addition, the ranking of probability of every clinical outcome was estimated by comparing the surface under the cumulative ranking curve. FindingsCompared with dabigatran, both edoxaban and aspirin + warfarin exhibited a higher rate of all-cause stroke (OR, 2.84 [95% CrI, 1.17–6.97]; OR, 3.42 [95% CrI, 1.20–9.84]). With respect to intracranial hemorrhage, aspirin + clopidogrel yielded worse outcomes than 7 treatments, including placebo, apixaban, aspirin, aspirin + dipyridamole, cilostazol, clopidogrel, and dabigatran (OR, 2.21 [95% CrI, 1.45–3.40]; OR, 2.11 [95% CrI, 1.05–4.17]; OR, 1.53 [95% CrI, 1.11–2.15]; OR, 1.78 [95% CrI, 1.01–3.03]; OR, 4.17 [95% CrI, 1.37–14.28]; OR, 1.85 [95% CrI, 1.22–2.86]; and OR, 2.56 [95% CrI, 1.37–4.76]). In terms of ischemic stroke, dabigatran provided better efficacy than placebo, aspirin, and aspirin + dipyridamole (OR, 0.36 [95% CrI, 0.18–0.72]; OR, 0.43 [95% CrI, 0.21–0.84]; and OR, 0.41 [95% CrI, 0.17–0.94]). As for mortality, dabigatran resulted in a lower mortality compared with aspirin, aspirin + clopidogrel, edoxaban, and warfarin (OR, 0.48 [95% CrI, 0.23–0.97]; OR, 0.40 [95% CrI, 0.17–0.92]; OR, 0.27 [95% CrI, 0.10–0.72]; and OR, 0.52 [95% CrI, 0.28–0.92]). ImplicationsThere are still some limitations to our NMA research. For instance, the lack of direct evidence for some therapies resulted in inconsistencies, particularly for warfarin compared with placebo and clopidogrel under different end points. Moreover, the included randomized controlled trials for patients with cardiovascular and cerebrovascular diseases are relatively broad, involving atrial fibrillation, myocardial infarction, and large-artery atherosclerosis stroke. Although further research is needed, dabigatran is highly recommended based on the present NAM for the treatment of cardiovascular and cerebrovascular diseases due to the drug’s efficacy and safety.

Hemorrhagic and ischemic outcomes of Heparin vs. Bivalirudin in carotid artery stenting: A meta-analysis of studies.

Bivalirudin, has been shown to have comparable efficacy and better safety profile when compared to unfractionated heparin (UFH) in percutaneous coronary interventions. Bivalirudin's safety in carotid artery stenting (CAS) was associated with better outcomes than heparin in some studies. In this Meta analysis we examine the hemorrhagic and ischemic outcomes associated with Bivalirudin compared to UFH during CAS. A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE, and CENTRAL. Random-effects meta-analysis method was used to pool risk ratio (RR) for both Heparin and Bivalirudin with 95% confidence interval (CI). Study outcomes included hemorrhagic complications; major/minor bleeding and intracranial hemorrhage (ICH) as well as ischemic complications including ischemic stroke, myocardial infarction, and 30 day mortality. A total of four studies were included enrolling 7,784 patients. Compared to UFH, Bivalirudin was associated with significantly lower major bleeding events with a relative risk (RR) of 0.53 (95% CI: 0.35-0.80; I2 = 0%). Minor bleeding events were significantly lower in the Bivalirudin group with a RR of 0.41 (95% CI: 0.2-0.82; I2 = 0%). Looking into other outcomes, there were no significant differences between anticoagulation strategies in terms of ischemic stroke (RR 0.8, with 95% CI: 0.60-1.06), intracranial hemorrhage (RR 0.73 with 95% CI: 0.27-1.98), myocardial infarction (RR 1.01 with 95% CI: 0.59-1.73) or 30 day mortality (RR 0.83 with 95% CI: 0.47-1.47). Compared to UFH, Bivalirudin is associated with lower bleeding risk when used during CAS. © 2016 Wiley Periodicals, Inc.