Risk Of Transient Ischemic Attack Research Articles

Additional predictors of stroke and transient ischaemic attack in BEFAST positive patients in out-of-hours emergency primary care

Introduction In patients suspected of stroke or transient ischemic attack (TIA), rapid triaging is imperative to improve clinical outcomes. For this purpose, balance-eye-face-arm-speech-time (BEFAST) items are used in out-of-hours primary care (OHS-PC). We explored the risk of stroke and TIA among BEFAST positive patients calling to the OHS-PC, and assessed whether additional predictors could improve risk stratification. Methods This is a cross-sectional study of retrospectively gathered routine care data from telephone triage tape-recordings of patients calling the OHS-PC with neurological deficit symptoms, classified as BEFAST positive. Four models–with the predictors age, sex, a history of cardiovascular or cerebrovascular disease, and cardiovascular risk factors–were fitted using logistic regression to predict the outcome stroke or TIA. Likelihood ratio testing was used to select the best model, which was subsequently internally validated. Results The risk of stroke or TIA diagnosis was 52% among 1,289 BEFAST positive patients, median age 72 years, 56% female sex. Of patients with the outcome stroke/TIA, 24% received a low urgency allocation, while 92% had signs or symptoms when calling. Only the addition of age and sex improved predicting stroke or TIA (internally validated c-statistic 0.72, 95%CI 0.69–0.75). The predicted risk of stroke or TIA remained below 20% in those aged below 40. Females aged 70 or over and males aged 55 or over, had a predicted risk above 50%. Discussion Urgency allocation appears to be suboptimal in BEFAST positive patients calling the OHS-PC. Risk stratification could be improved in this setting by adding age and sex.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database.

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS. This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI). Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups. Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

Association of Acute Incidental Cerebral Microinfarcts With Subsequent Ischemic Stroke in Patients With Cancer: A Population-Based Study.

Incidental diffuse-weighted imaging (DWI)-positive subcortical and cortical lesions, or acute incidental cerebral microinfarcts (CMIs), are a common type of brain ischemia, which can be detected on magnetic resonance DWI for approximately 2 weeks after occurrence. Acute incidental CMI was found to be more common in patients with cancer. Whether acute incidental CMI predicts future ischemic stroke is still unknown. We aimed to examine the association between acute incidental CMI in patients with cancer and subsequent ischemic stroke or transient ischemic attack (TIA). This is a retrospective cohort study. We used Clalit Health Services records, representing over half of the Israeli population, to identify adults with lung, breast, pancreatic, or colon cancer who underwent brain MRI between January 2014 and April 2020. We included patients who underwent scan between 1 year before cancer diagnosis and 1 year after diagnosis. Primary outcome was ischemic stroke or TIA using International Classification of Diseases, Ninth Revision codes. Secondary outcomes were intracranial hemorrhage (ICH) and mortality. Records were followed from first MRI until primary outcome, death, or end of follow-up (January 2023). Cox proportional hazards models were used to calculate hazard ratio (HR) for patients with and without acute incidental CMI, as a time-dependent covariate. The study cohort included 1,618 patients with cancer, among whom, 59 (3.6%) had acute incidental CMI on at least 1 brain MRI. The median (interquartile range) time from acute incidental CMI to stroke or TIA was 26 days (14-84). On multivariable analysis, patients with acute incidental CMI had a higher stroke or TIA risk (HR 2.97, 95% CI 1.08-8.18, p = 0.035) compared with their non-CMI counterparts. Acute incidental CMIs were also associated with mortality after multivariable analysis (HR 2.76, 95% CI 2.06-3.71, p < 0.001); no association with ICH was found. Acute incidental CMI on brain MRI in patients with active cancer is associated with an increased risk of near-future ischemic stroke or TIA and mortality. This finding might suggest that randomly detected acute incidental CMI in patients with cancer may guide primary cerebrovascular risk prevention and etiologic workup.

Stroke risk after transcatheter aortic valve replacement in patients with carotid stenosis: A systematic review and meta-analysis

BackgroundStroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS. MethodsWe searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality. ResultsWe identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95–2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02–2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79–1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85–1.45; p = 0.43, respectively). ConclusionsCAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS.

Abstract TMP102: Association of Lipoprotein(a) With Stroke and Cerebral Injury: Insights From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and Investigation of Neurocognitive Aging-MRI (SOL-INCA MRI)

Introduction: Lipoprotein(a) [Lp(a)] is a known risk factor for cardiovascular disease; however, its association with cerebrovascular disease is not as well established. Methods: Data from HCHS/SOL, a population-based cohort of Hispanics/Latinos, was utilized. We included 16,039 participants with measured Lp(a) levels (nmol/L) and self-reported history of prevalent stroke or transient-ischemic attack (TIA) from Visit 1. Data from SOL-INCA MRI (ancillary study conducted after Visit 2) was utilized to identify a subset of 2,668 HCHS/SOL participants with brain MRI. Linear and logistic regression was used to study the association of Lp(a) with 1. Self-reported stroke or TIA; 2. Cerebral injury defined as self-reported stroke or TIA or evidence of a stroke on brain MRI; and 3. White matter hyperintensity (WMH) volume modeled as log (WMH/total cranial volume). Lp(a) was modeled as a continuous variable and as quintiles. Sampling weights and surveys methods were used to account for the complex HCHS/SOL design. Results: HCHS/SOL mean age ± SE was 41.1 ± 0.3 years, 52.0% female, and median (IQR) Lp(a) level 19.7 (7.3-60.6) nmol/L. SOL-INCA MRI mean age ± SE was 49.9 ± 0.4 years, 56.4% female, and median (IQR) Lp(a) level 21.7 (8.1-62.9). A ten nmol/L unit increase in Lp(a) was significantly associated with a higher risk of self-reported prevalent stroke or TIA (OR 1.03, 95% CI: 1.02-1.05, p = 0.0002). Lp(a)&gt;77 nmol/L (5 th quintile) was significantly associated with higher risk of self-reported prevalent stroke or TIA (OR 1.8, 95% CI: 1.2-2.8, p = 0.009) compared to Lp(a) &lt;6 nmol/L (1 st quintile) as reference. A ten unit increase in Lp(a) was significantly associated with higher odds of cerebral injury (OR 1.03, 95% CI: 1.02-1.05, p&lt;0.0001). Lp(a)&gt;77 nmol/L was significantly associated with cerebral injury (OR 1.8, 95% CI 1.3- 2.6, p=0.002) as compared to Lp(a) &lt;6 nmol/L. A ten unit increase in Lp(a) was also significantly associated with increasing WMH volume (β 0.02, p=0.0002). Conclusions: Lp(a) is significantly associated with self-reported prevalent stroke or TIA, brain MRI evidence of cerebral injury, and WMH, in a large diverse population of Hispanics/Latinos, suggesting that Lp(a) may be a modifiable risk factor for cerebrovascular disease.

Abstract 10: Enhanced Benefits of the Life's Essential 8 in APOE Epsilon 4 Carriers

Background: Adherence to the American Heart Association's Life’s Essential 8 (LE8) reduces the risk of cardiovascular disease. While the epsilon (ε) 4 variants within the APOE gene have been extensively investigated as a risk factor for dementia and stroke, APOE ε4 carriers have not been thoroughly studied as an at-risk population. We hypothesized that, compared to non-carriers, APOE ε4 carriers derive additional neuro- and cardiovascular health benefits from LE8 optimization. Methods: We used longitudinal data from the UK Biobank (UKB), a large, prospective study undertaken in the UK. Participants with prior stroke, transient ischemic attack (TIA) or myocardial infarction (MI) were excluded. The independent variable or “exposure” was the LE8 score, which was based on data on blood pressure, blood glucose and cholesterol, body mass index, smoking, physical activity, sleep duration and diet. Our outcome was a composite of stroke, TIA or MI. Multivariable logistic regression models with product terms were used to test for interaction between APOE ε4 status and LE8 score. Results: Of the 317,174 UKB participants (mean age 56 years, 54% female) with available genetic and LE8 data, 81,877 (26%) were APOE ε4 carriers (1 or 2 alleles), including 74,384 (91%) heterozygous and 7,493 (9%) homozygous. Among all participants, a 1 SD increase in the LE8 score correlated with a 28% risk reduction for incident stroke, TIA, or MI (OR 0.72, 95%CI 0.71-0.73; p&lt;0.001). APOE ε4 status significantly modified the association between the LE8 score and the composite risk of stroke, TIA, or MI (interaction p=0.008): while APOE ε4 carriers had a 30% risk reduction (OR 0.70, 95%CI 0.68-0.72; p&lt;0.001) per 1 SD increase in the LE8 score, APOE ε4 non-carriers had a 27% risk reduction (OR 0.73, 95%CI 0.72-0.74; p&lt;0.001). Thus, APOE-e4 carriers experienced an 11% increase in benefit. Conclusion: Compared to non-carriers, middle-aged APOE ε4 carriers without a history of vascular events derive greater benefit from LE8 optimization. Now that direct-to-consumer genotyping companies are routinely returning APOE data to millions of Americans, our findings provide important information to educate this population on proven strategies that improve long-term neuro- and cardiovascular outcomes.

Abstract WP243: Elevated Lipoprotein(a) as a Predictor for Recurrent Ischemic Cerebrovascular Events: A Meta-Analysis of Cohort Studies

Introduction: Elevated levels of Lipoprotein(a) [Lp(a)] have been associated with an increased risk of incidental acute ischemic stroke (AIS). Our study represents the first meta-analysis investigating the relationship between Lp(a) levels and the recurrence of AIS or transient ischemic attacks (TIA) in both adult and pediatric populations. Methods: We conducted a systematic search of PubMed and Google Scholar databases up to August 2023, utilizing medical subject headings and title/abstract terms. Studies reporting on Lp(a) levels predicting recurrent AIS or TIA were screened. From 85 identified studies, 8 met our inclusion criteria: 5 focusing on adults and 3 on pediatric cohorts. Binary random effects models were used to estimate pooled unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI). Subgroup analysis was performed by country. Sensitivity analysis was done by the leave-one-out method, and the heterogeneity was assessed with I 2 statistics. Results: Our analysis included data from 13,549 patients. The mean age in years was 66 for adults and 7.6 for the pediatric cohort. The majority of the cohorts were male and identified as being of a white racial background. The median follow-up duration was 22.5 months. Elevated Lp(a) indicated an unadjusted OR of 1.60 (95% CI: 1.18-2.16) for recurrent AIS or TIA, with moderate heterogeneity (I 2 =56.17%, p=0.003) and the association validated by sensitivity analysis. When adjusted, the OR increased to 1.84 (95% CI: 1.20-2.84) with high heterogeneity (I 2 =82.36%, p&lt;0.001). Country-specific sub-analysis identified the highest OR in Germany, followed by China and the USA. Conclusion: Elevated Lp(a) levels corresponded to a 60% unadjusted and 84% adjusted increase in the risk of recurrent AIS or TIA. This underscores the significance of Lp(a) as a valuable predictor for recurring cerebrovascular events, offering insight to inform clinical management and decision-making.

Quantitative patient graph analysis for transient ischemic attack risk factor distribution based on electronic medical records

A transient ischemic attack (TIA) affects millions of people worldwide. Although TIA risk factors have been identified individually, a systemic quantitative analysis of all health factors relevant to TIA using electronic medical records (EMR) remains lacking. This study employed a data-driven approach, leveraging hospital EMR data to create a TIA patient health factor graph. This graph consisted of 737 TIA and 737 control patient nodes, 740 health factor nodes, and over 33,000 relations between patients and factors. For all health factors in the graph, the connection delta ratios (CDRs) were determined and ranked, generating a quantitative distribution of TIA health factors. A literature review confirmed 56 risk factors in the distribution and unveiled a potential new risk factor “rhinosinusitis” for future validation. Moreover, the patient graph was visualized together with the TIA knowledge graph in the Unified Medical Language System. This integration enables clinicians to access and visualize patient data and international standard knowledge within a unified graph. In conclusion, graph CDR analysis can effectively quantify the distribution of TIA risk factors. The resulting TIA risk factor distribution might be instrumental in developing new risk prediction machine learning models for screening and early detection of TIA.

Association of device detected atrial high rate episodes with embolic events

Abstract Background Subclinical atrial fibrillation (AFib) is a common etiology of embolic events such as embolic strokes of undetermined source. With the advent of cardiac implantable electronic devices (CIED), there has been increased detection of subclinical AFib, or atrial high rate episodes (AHRE) in asymptomatic patients without a known diagnosis of AFib. The clinical significance of AHRE detected with CIED remains poorly characterized with studies reporting conflicting results. The purpose of this meta-analysis is to evaluate the association of AHRE with cerebrovascular accidents (CVA), transient ischemic attacks (TIA), and systemic embolic events. Methods A literature search was conducted for studies reporting on the association of subclinical AFib or AHRE with CVA, TIA, and systemic embolic events. The search included the following databases: Ovid MEDLINE, EMBASE, Google Scholar, and Web of Science. The search was not restricted to time or publication status. Results A total of 19 studies and 50,968 patients (12,879 with AHRE vs 38,089 without AHRE) were included. Mean follow-up was 32 months, mean age was 72 years old, 53.3% were male. Patients with device detected AHRE had increased risk of composite endpoint of CVA, TIA, and systemic embolic events (OR 2.98, 95% CI 2.03-4.39; P&amp;lt;0.01). Subgroup analysis by maximum AHRE burden demonstrated that both maximum AHRE burden &amp;gt;24 hours and burden &amp;lt;24 hours are associated with increased risk of CVA, TIA, and systemic embolic events (OR 4.82, 95% CI 2.07-11.24; p&amp;lt;0.01; OR 1.55, 95% CI 1.11-2.15; p&amp;lt;0.01). The overall effect size is larger for maximum AHRE burden &amp;gt;24 hours compared to &amp;lt;24 hours (Z=3.64 vs Z=2.61). Conclusions Our results suggest that AHRE detected with CIED is associated with increased risk of CVA, TIA, and systemic embolic events regardless of maximum AHRE burden &amp;gt;24 hours or &amp;lt;24 hours. Additional studies are required to determine the utility anticoagulation therapy for treatment of asymptomatic patients with device detected AHRE.

Abstract 12836: Safety and Efficacy of Left Atrial Appendage Occlusion in Patients With Chronic Kidney Disease: A Meta-Analysis

Introduction: Left atrial appendage occlusion (LAAO) has been recognized as an alternative to preventing thromboembolic stroke in selected patients with non-valvular atrial fibrillation (AF). However, limited evidence exists regarding the safety of LAAO in patients with chronic kidney disease (CKD). This meta-analysis aims to evaluate the safety and efficacy of LAAO in CKD patients. Methods: We conducted a comprehensive search across various electronic databases, including PubMed, Embase, and the Cochrane Library, to identify relevant studies comparing the outcomes of CKD and non-CKD patients undergoing LAAO. The outcomes of interest included procedural success, in-hospital mortality, major bleeding, stroke, transient ischemic attack (TIA), and pericardial effusion/tamponade. The outcomes were pooled using the Hartung-Knapp-Sidik-Jonkman random-effects model, and the results were expressed as odds ratios (OR) with their corresponding 95% confidence intervals (CI). Results: Seven studies involving 38,184 patients (5,742 CKD, 32,442 non-CKD) were included in the final analysis. The rate of procedural success (98.4% vs. 97.2%, OR 1.64, 95% CI: 0.78-3.45, p=0.19) was similar between both groups. Regarding procedural complications, there were no significant differences in terms of the risk of in-hospital mortality (OR 1.87, 95% CI: 0.60-5.82, p=0.28), stroke (OR 2.19, 95% CI: 0.76-6.29, p=0.15), TIA (OR 1.64, 95% CI: 0.78-3.45, p=0.19), major bleeding (OR 1.85, 95% CI: 0.78-4.42, p=0.16), or pericardial effusion/tamponade (OR 1.23, 95% CI: 0.76-2.00, p=0.39) between the two patient groups. Conclusions: Our study demonstrates comparable safety and efficacy of LAAO in patients with CKD compared to those without CKD. Further large prospective studies are warranted to confirm these findings.

Abstract 136: Antiplatelet Regimens for Secondary Prevention in Minor Ischemic Stroke or TIA: A Network Meta‐Analysis

Introduction There is increased risk of major cardiovascular events among patients with minor ischemic stroke or transient ischemic attack (TIA) [1]. Antiplatelet drugs have been proven to reduce the risk of major cardiovascular events and highly recommended for secondary stroke prevention in this population [2]. However, using antiplatelets has shown an increase in the risk of bleeding events. Hence there are multiple antiplatelet regimens, we aim to investigate the efficacy and safety of these different regimens in minor ischemic stroke defined as National Institutes of Health Stroke Scale (NIHSS) score of 5 or less and high‐ risk TIA). Methods A comprehensive literature search of (PubMed, Cochrane, Scopus, and WOS) was conducted to identify randomized controlled trials comparing different antiplatelet regimens in patients with minor ischemic stroke or TIA. Frequentist NMA was conducted to estimate relative risks (RR) and 95% confidence intervals (CI) for the outcomes of interest using R statistical programming language [3]. The primary outcome measure was recurrent stroke while secondary outcomes included, any bleeding events, serious adverse events (SAEs), hemorrhagic stroke, myocardial infarction (MI), cardiovascular mortality, and all‐cause mortality. Results Five RCTs with 34,941 participants were included. Compared to SAPT (aspirin alone), both DAPT regimens (aspirin + clopidogrel and aspirin + ticagrelor) demonstrated a significant reduction in stroke recurrence (RR: 0.72 with 95% CI [0.63, 0.82], P &lt; 0.01) and (RR: 0.75 with 95% CI [0.64, 0.87], P &lt; 0.01), respectively. However, both DAPT regimens were associated with a higher risk of bleeding events (RR: 1.95 with 95% CI [1.09, 3.50], P = 0.02), (RR: 3.07 with 95% CI [1.16, 8.15], P = 0.02), respectively. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events. Conclusion Our findings indicate that DAPT regimens were effective in reducing stroke recurrence compared to SAPT. However, caution is warranted as both DAPT regimens were associated with a higher risk of bleeding events. Clinicians should weigh the potential benefits of reduced stroke recurrence with DAPT against the increased risk of bleeding events. Further research and clinical trials assessing both safety and efficacy are warranted to better understand the optimal prevention approach for this specific patient population.

Underlying Causes of TIA and Minor Ischemic Stroke and Risk of Major Vascular Events

The coexistence of underlying causes in patients with transient ischemic attack (TIA) or minor ischemic stroke as well as their associated 5-year risks are not well known. To apply the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other cause, or dissection) grading system to assess coexistence of underlying causes of TIA and minor ischemic stroke and the 5-year risk for major vascular events. This international registry cohort (TIAregistry.org) study enrolled 4789 patients from June 1, 2009, to December 31, 2011, with 1- to 5-year follow-up at 61 sites in 21 countries. Eligible patients had a TIA or minor stroke (with modified Rankin Scale score of 0 or 1) within the last 7 days. Among these, 3847 patients completed the 5-year follow-up by December 31, 2016. Data were analyzed from October 1, 2022, to June 15, 2023. Five-year follow-up. Estimated 5-year risk of the composite outcome of stroke, acute coronary syndrome, or cardiovascular death. A total of 3847 patients (mean [SD] age, 66.4 [13.2] years; 2295 men [59.7%]) in 42 sites were enrolled and participated in the 5-year follow-up cohort (median percentage of 5-year follow-up per center was 92.3% [IQR, 83.4%-97.8%]). In 998 patients with probable or possible causal atherosclerotic disease, 489 (49.0%) had some form of small vessel disease (SVD), including 110 (11.0%) in whom a lacunar stroke was also probably or possibly causal, and 504 (50.5%) had no SVD; 275 (27.6%) had some cardiac findings, including 225 (22.6%) in whom cardiac pathology was also probably or possibly causal, and 702 (70.3%) had no cardiac findings. Compared with patients with none of the 5 ASCOD categories of disease (n = 484), the 5-year rate of major vascular events was almost 5 times higher (hazard ratio [HR], 4.86 [95% CI, 3.07-7.72]; P < .001) in patients with causal atherosclerosis, 2.5 times higher (HR, 2.57 [95% CI, 1.58-4.20]; P < .001) in patients with causal lacunar stroke or lacunar syndrome, and 4 times higher (HR, 4.01 [95% CI, 2.50-6.44]; P < .001) in patients with causal cardiac pathology. The findings of this cohort study suggest that in patients with TIA and minor ischemic stroke, the coexistence of atherosclerosis, SVD, cardiac pathology, dissection, or other causes is substantial, and the 5-year risk of a major vascular event varies considerably across the 5 categories of underlying diseases. These findings further suggest the need for secondary prevention strategies based on pathophysiology rather than a one-size-fits-all approach.

Ticagrelor plus aspirin vs clopidogrel plus aspirin in mild non-cardioembolic ischemic stroke: A protocol of a randomized, controlled, active comparator arm, outcome assessor blind, feasibility study

Background &amp; Objectives: The risk of recurrence after a transient ischemic attack (TIA) or minor stroke is high especially within three months after first event. The aim of study is assessing the efficacy of ticagrelor plus aspirin in reduction of mild non-cardioembolic ischemic stroke or high risk TIA recurrence during first 3 months. Methods: This is a randomized, controlled, active comparator arm, outcome assessor blind, parallel group, feasibility study design on 90 patients with diagnosis of non-cardioembolic minor ischemic stroke or high risk TIA admitted in Bou-Ali Sina Hospital, Sari, Iran. After meeting all inclusion and exclusion criteria, patients will be randomized to ticagrelor 90 mg BID plus aspirin (ASA) 80 mg daily or clopidogrel 75 mg daily plus ASA 80 mg daily (1:1 ratio) until 21 days and then ASA 80 mg daily. Participants will be visited at month one and three. Any adverse events, serious side effects and outcome events will be recorded. The primary outcome is defined as ischemic stroke recurrence. Conclusion: Ticagrelor plus ASA is expected to be effective for prevention of recurrence in mild non-cardioembolic stroke and high risk TIA. Trial Registration: ClinicalTrials.gov: NCT04738097

Association between vertebrobasilar artery geometry and vertebrobasilar stenosis, recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA. MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed. ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010). ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.

Site Variability in Cerebral Embolic Protection for Transcatheter Aortic Valve Implantation and Association With Outcomes

BackgroundThe effectiveness of CEPD in mitigating post-TAVI stroke remains uncertain, and therefore CEPD may be utilized differently across US hospitals. This study aims to characterize the hospital-level pattern of cerebral embolic protection device (CEPD) use during transcatheter aortic valve implantation (TAVI) in the United States and its association with outcomes. MethodsPatients treated with nontransapical TAVI in the 2019 Nationwide Readmissions Database were included. Hospitals were categorized as CEPD non-users and CEPD users. The following outcomes were compared: the composite of in-hospital stroke or transient ischemic attack (TIA), in-hospital ischemic stroke, death, and cost of hospitalization. Logistic regression models were used for risk adjustment of clinical outcomes. ResultsOf 41,822 TAVI encounters, CEPD was used in 10.6% (n = 4422). Out of 392 hospitals, 65.8% were CEPD non-user hospitals and 34.2% were CEPD users. No difference was observed between CEPD non-users and CEPD users in the risk of in-hospital stroke or TIA (adjusted odds ratio (OR) = 0.99 [0.86-1.15]), ischemic stroke (adjusted OR = 1.00 [0.85-1.18]), or in-hospital death (adjusted OR = 0.86 [0.71-1.03]). The cost of hospitalization was lower in CEPD non-users. ConclusionsTwo-thirds of hospitals in the US do not use CEPD for TAVI, and no significant difference was observed in neurologic outcomes among patients treated at CEPD non-user and CEPD user hospitals.

Percutaneous angioplasty and/or stenting versus aggressive medical therapy in patients with symptomatic intracranial atherosclerotic stenosis: a 1-year follow-up study.

Symptomatic intracranial atherosclerotic stenosis (sICAS) is one of the common causes of ischemic stroke. However, the treatment of sICAS remains a challenge in the past with unfavorable findings. The purpose of this study was to explore the effect of stenting versus aggressive medical management on preventing recurrent stroke in patients with sICAS. We prospectively collected the clinical information of patients with sICAS who underwent percutaneous angioplasty and/or stenting (PTAS) or aggressive medical therapy from March 2020 to February 2022. Propensity score matching (PSM) was employed to ensure well-balanced characteristics of two groups. The primary outcome endpoint was defined as recurrent stroke or transient ischemic attack (TIA) within 1 year. We enrolled 207 patients (51 in the PTAS and 156 in the aggressive medical groups) with sICAS. No significant difference was found between PTAS group and aggressive medical group for the risk of stroke or TIA in the same territory beyond 30 days through 6 months (P = 0.570) and beyond 30 days through 1 year (P = 0.739) except for within 30 days (P = 0.003). Furthermore, none showed a significant difference for disabling stroke, death and intracranial hemorrhage within 1 year. These results remain stable after adjustment. After PSM, all the outcomes have no significant difference between these two groups. The PTAS has similar treatment outcomes compared with aggressive medical therapy in patients with sICAS across 1-year follow-up.

Managing Recurrent Ischemic Cerebrovascular Events in Patients with Atrial Fibrillation Compliant with Oral Anticoagulant Therapy (P6-5.001)

<h3>Objective:</h3> To evaluate if oral anticoagulant therapy change (OAC change) or adding antiplatelet therapy to anticoagulation (AC+AP) in patients with nonvalvular atrial fibrillation (AF) and acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite OAC compliance, is associated with lower risk of recurrent cerebrovascular events compared to patients that continued the same anticoagulant regimen. <h3>Background:</h3> Patients with AF still have an appreciable risk of AIS or TIA despite compliance with OAC. Yet little is known about the best management options in this population. <h3>Design/Methods:</h3> We reviewed all consecutive patients with AF on OAC that presented with AIS/TIA to our tertiary academic stroke center between 2011–2021. Baseline characteristics, type of index event, antithrombotic therapy before and after index event, subsequent recurrent AIS/TIA or major bleeding events were extracted. Fisher’s exact or Log-rank tests and logistic regression models were used to compare outcomes between OAC unchange vs OAC change, and AC+AP vs AC only groups. <h3>Results:</h3> 185 patients (mean age 78.3 ± 12 years) were included. 61% were males and 79 (42.7%) had AIS at index event. 17 (9%) had OAC change and 100 (79%) received AP+AC. 39 (21.15%) had recurrent AIS/TIA, and 28 (15.1%) had major bleeding following the index event. No significant difference was observed between OAC unchange versus OAC change groups regarding recurrent AIS/TIA (HR = 0.607, 95% CI: 0.229–1.609, p = 0.316) or major bleeding events (OR = 1.541, 95% CI: 0.391–10.299, p = 0.586). Additionally, no significant difference was observed between AC+AP versus AC groups regarding recurrent AIS/TIA (HR= 0.863, 95% CI: 0.430–1.732, p = 0.679) or major bleeding events (OR= 0.894, 95% CI: 0.377–2.135, p = 0.798). <h3>Conclusions:</h3> In patients with AF and acute ischemic cerebrovascular events despite OAC compliance, changing anticoagulant or adding antiplatelet agent may not decrease risk of future cerebrovascular events. <b>Disclosure:</b> Dr. Harahsheh has nothing to disclose. Mr. Elshaigi has nothing to disclose. Dr. Alhayek has nothing to disclose. Vanesa Vanderhye has nothing to disclose. Dr. O’Carroll has nothing to disclose. Dr. Dumitrascu has nothing to disclose.

90-Days Outcomes In Patients With Minor Strokes Or Transient Ischemic Attacks Discharged On Single Vs Dual Anti Platelet-Therapy In the Middle East (P7-5.019)

<h3>Objective:</h3> To compare the 90-day outcome in patients with minor stroke (MIS) or transient ischemic attack (TIA) who were discharged on single versus dual anti-platelet therapy after index event in the multiethnic Middle Eastern community. <h3>Background:</h3> Recent studies have shown that dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is effective for secondary prevention after minor ischemic stroke (MIS) or transient ischemic attack (TIA). However, there is paucity of data from middle east regarding role of such intervention and outcome of these patients <h3>Design/Methods:</h3> We inquired all Ischemic stroke and TIA patients from our prospectively collected stroke database admitted since January 2014. We separated them into two groups-discharged on single(SAP) vs DAPT. High risk group for recurrence was defined as patients with ABCD2 score of ≥ 4 or more and NIHSS ≤ 3 at index event. We assessed the outcome as measured with modified Rankin Score (mRS), recurrent ischemic stroke, and other vascular events. <h3>Results:</h3> The data provided yielded 1357 (16.8%) patients with TIAs and 6725 (83.2%) with MIS. Of these only 35% (1481/4219) of high risk patient were discharged on DAPT (38.5% of TIA patients and 30.0% MIS patients). DAPT was initiated within 24 hours of arrival at hospital in 86.3% of patients (p&lt;0.001) with a mean duration of 12.5 ±15.6 hours (p&lt;0.001). Poor outcome (mRS 3–6) (27.9% vs 15.1%, p&lt;0.001), and increased mortality (2.2% vs 1.1%, p&lt;0.001) was more significant in patients discharged on SAP versus DAPT. <h3>Conclusions:</h3> The rates of DAPT in patients with TIA and MIS is low. Patients with high risk TIA and MIS discharged on DAPT has better outcome at 90-days in ethnically diverse group of patients in the Middle East. <b>Disclosure:</b> Ms. Naveed has nothing to disclose. Dr. Akhtar has nothing to disclose. Dr. Shuaib has nothing to disclose. Dr. Al Jerdi has nothing to disclose.

Is Dual Antiplatelet Therapy Underutilized Following TIA and Minor Stroke? (S3.006)

<h3>Objective:</h3> Our aim was to identify the variations in single vs dual antiplatelet prescribing practices at the time of discharge within a major Stroke Clinical Network. <h3>Background:</h3> Initiation of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel plays a significant role in the secondary prevention of recurrent acute ischemic events following high risk transient ischemic attack (TIA) and minor acute ischemic stroke (AIS). However, some patients do not receive the same targeted therapy on discharge and are only maintained on single antiplatelet therapy. <h3>Design/Methods:</h3> The GWTG registry was queried for patients &gt;18 years old with a TIA or a minor AIS (NIHSS ≤5), who were admitted to a single hospital network between January 2018 and December 2021. Demographics collected including age, race, gender, and BMI. Patients on concurrent anticoagulation were excluded. We evaluated antiplatelet discharge practices at the tertiary stroke center vs the entire network, among men vs. women, African Americans (AA) vs whites, age 18–70 vs &gt;70 years, and across BMI. <h3>Results:</h3> Among 2953 patients with a TIA or minor AIS, the mean age was 67.3 (SD +/− 13.8 years), with 42% &gt;70 years of age. 47.8% were women; 37% were AA; 60% were white. DAPT was prescribed at the time of discharge to 40% of patients overall. Gender was a significant factor with men (43%) more likely to get prescribed DAPT than females (37%) (p=.002). While BMI did not have a lone effect on number of antiplatelets (AP) prescribed, when it was included as a covariate, there was a significant effect on the number of AP prescribed; with the higher the BMI, the less likely patients were to receive DAPT. <h3>Conclusions:</h3> We identified underutilization of DAPT following TIA and minor stroke across a health system, especially in women. Targeted intervention to increase DAPT use could lead to reduced rate of short-term stroke recurrence. <b>Disclosure:</b> Dr. Solomonow has nothing to disclose. Dr. Marks has nothing to disclose. Karen Yarbrough has nothing to disclose. Dr. Mehndiratta has nothing to disclose. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astra Zeneca. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Calgary. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Ramar &amp; Paradiso. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Cole, Scott, Kissane. The institution of Dr. Chaturvedi has received research support from NINDS.

Divergence Between Clinical Trial Evidence and Actual Practice in Use of Dual Antiplatelet Therapy After Transient Ischemic Attack and Minor Stroke

Randomized controlled trials (RCTs) proved that short-term (21-90 days) dual antiplatelet therapy (DAPT) reduces the risk of early ischemic recurrences after a noncardioembolic minor stroke or high-risk transient ischemic attack (TIA) without substantially increasing the hemorrhagic risk. We aimed at understanding whether and how real-world use of DAPT differs from RCTs. READAPT (Real-Life Study on Short-Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or TIA) is a prospective cohort study including >18-year-old patients treated with DAPT after a noncardioembolic minor ischemic stroke or high-risk TIA from 51 Italian centers. The study comprises a 90-day follow-up from symptom onset. In the present work, we reported descriptive statistics of baseline data of patients recruited up to July 31, 2022, and proportions of patients who would have been excluded from RCTs. We compared categorical data through the χ² test. We evaluated 1070 patients, who had 72 (interquartile range, 62-79) years median age, were mostly Caucasian (1045; 97.7%), and were men (711; 66.4%). Among the 726 (67.9%) patients with ischemic stroke, 226 (31.1%) did not meet the RCT inclusion criteria because of National Institutes of Health Stroke Scale score >3 and 50 (6.9%) because of National Institutes of Health Stroke Scale score >5. Among the 344 (32.1%) patients with TIA, 69 (19.7%) did not meet the RCT criteria because of age, blood pressure, clinical features, duration of TIA, presence of diabetes score <4 and 252 (74.7%) because of age, blood pressure, clinical features, duration of TIA, presence of diabetes score <6 and no symptomatic arterial stenosis. Additionally, 144 (13.5%) patients would have been excluded because of revascularization procedures. Three hundred forty-five patients (32.2%) did not follow the RCT procedures because of late (>24 hours) DAPT initiation; 776 (72.5%) and 676 (63.2%) patients did not take loading doses of aspirin and clopidogrel, respectively. Overall, 84 (7.8%) patients met the RCT inclusion/exclusion criteria. The real-world use of DAPT is broader than RCTs. Most patients did not meet the RCT criteria because of the severity of ischemic stroke, lower risk of TIA, late DAPT start, or lack of antiplatelet loading dose. URL: https://www. gov; Unique identifier: NCT05476081.