Risk Of Transient Ischemic Attack Research Articles

Stroke and Thromboembolic Events in Men with Prostate Cancer Treated with Definitive Radiation Therapy with or without Androgen Deprivation Therapy

There is conflicting evidence on the association between the use of androgen deprivation therapy (ADT) and the risk of developing stroke and thromboembolic events. Prior observational studies may be prone to selection bias. We hypothesize that there is an association between ADT use and the development of stroke, transient ischemic attack (TIA), deep vein thrombosis (DVT), and pulmonary embolism (PE) in men with prostate cancer (PC) treated with definitive radiation therapy (RT) after controlling for multiple sources of selection bias. This is an observational cohort study of men diagnosed with non-metastatic PC at the United States Department of Veterans Affairs between January 1, 2001 and October 31, 2015 who received definitive RT with or without ADT. Patients with missing covariates, including prostate specific antigen (PSA), Gleason score, clinical T, M, and N stages, and income were excluded. We excluded patients with a previous stroke, TIA, dementia, mild cognitive impairment, DVT, or PE at any time before their PC diagnosis. Finally, patients who initiated ADT more than one year after their PC diagnosis were excluded. Fine-Gray competing risks regression was used to evaluate the association of ADT with stroke and thromboembolic events. Patients who initiated ADT of any sort within 1 year of PC diagnosis were considered to be exposed to ADT. Outcomes were the development of stroke, TIA, DVT, or PE. Variables included in the Fine-Gray model were age, CCI score, statin use, antiplatelet use, antihypertensive use, alcohol abuse, substance abuse, race, smoking status, region, Gleason score, income, education, clinical T stage, PSA, and year of diagnosis. The cohort included 44,246 men followed for a median of 6.8 years. A total of 27,971 patients received RT alone while 16,275 patients received RT and ADT. During the study follow-up, 2,517 patients experienced stroke, 1,141 experienced TIA, 1,286 developed DVT, and 653 developed PE. In the multivariable competing risk model, there was an overall significant association between ADT and stroke (subdistribution hazard ratio (SHR) =1.19, 95% CI=1.09-1.30, p<0.01), TIA (SHR=1.24, 95% CI=1.08-1.41, p<0.01), and DVT (SHR=1.18, 95% CI=1.04-1.34, p<0.01). While there was no overall association between ADT and PE (Table 2; SHR=1.16, 95% CI=0.98-1.39, p-value=0.08), there was an association between ADT length>1 year and PE (SHR=1.34, 95% CI=1.06-1.69, p-value=0.03). We observed an increase in the risk of stroke, TIA, and DVT among a large cohort of men with PC who received ADT with definitive RT. In the subset of men who received ADT for more than one year, we also found an association between ADT and PE. These results may help to clarify concerns regarding the long-term risks of ADT on cerebrovascular and cardiovascular disease in the treatment of PC.

Intracranial Artery Calcium Burden Predicts Recurrent Cerebrovascular Events in Transient Ischaemic Attack Patients

Background: Patients with initial transient ischaemic attack (TIA) subsequently have a higher risk of recurrent TIA or acute ischemic stroke (AIS). The role of scoring intracranial arterial calcification (IAC) in predicting the prevalence of stroke remains unclear. We aim to evaluate if radiological CT calcium score measuring IAC burden could predict future ischemic events in a cohort of TIA patients. Methods: We studied consecutive patients from July 2014 to December 2015 who presented with first episode of TIA. All patients had noncontrasted CT or CT-angiogram of the brain on admission. CT calcium score (cm3) was quantified by measuring calcium deposition in the bilateral internal carotid arteries, middle cerebral arteries, and vertebrobasilar system. Patients were followed up for 2 years and ischemic events for either recurrent TIA or AIS were recorded. We compared patients in terms of clinical profile at presentation and CT calcium score using appropriate univariate and multivariable analyses. Results: Of 156 TIA patients studied, 22% (n = 35) had recurrent TIA or AIS within 2 years of follow-up. On univariate analyses, recurrent TIA/AIS was associated with gender (OR 0.61; 95%CI 0.40-0.95; P = .038), hypertension (mean difference 2.49; 95%CI 1.08-5.75; P = .030) and higher CT calcium score (mean difference 0.84 95%CI 0.16-1.52 P = .016). On multivariable logistic regression, a higher CT calcium score was significantly associated with recurrent TIA/AIS (adjusted OR 1.25 95%CI 1.01-1.55 P = .042). Conclusions: In TIA patients, higher IAC burden by measurement of a quantitative CT calcium score may be associated with recurrent ischemic events.

Japanese Versus Non-Japanese Patients with Transient Ischemic Attack or Minor Stroke: Subanalysis of TIA registry.org

BackgroundTIAregistry.org is an international cohort of patients with transient ischemic attack (TIA) or minor stroke within 7 days before enrollment in the registry. Main analyses of 1-year follow-up data have been reported.5 We conducted subanalysis on the baseline and 1-year follow-up data of Japanese patients. MethodsThe patients were classified into 2 groups based on Japanese ethnicity, Japanese (345) and non-Japanese (3238), and their baseline data and 1-year event rates were compared. We also determined risk factors and predictors of 1-year stroke. ResultsCurrent smoking, regular alcohol drinking, intracranial arterial stenosis, and small vessel occlusion; and hypertension, dyslipidemia, coronary artery disease, and extracranial arterial stenosis were more and less common among Japanese patients, respectively. Stroke risk was higher and TIA risk was lower at 1-year follow-up among Japanese patients. The baseline risk factors for recurrent stroke were diabetes, alcohol drinking, and large artery atherosclerosis. Independent predictors of 1-year stroke risk were prior congestive heart failure and alcohol consumption. ConclusionsThe two populations of patients featured differences in risk factors, stroke subtypes, and outcome events. Predictors of recurrent stroke among Japanese patients included congestive heart failure and regular alcohol drinking. Strategies to attenuate residual risk of stroke aside from adherence to current guidelines should take our Japanese-patient specific findings into account.

Aspirin for Primary Prevention of Cardiovascular Events

BackgroundThe efficacy and safety of aspirin for primary prevention of cardiovascular disease (CVD) remain debatable. ObjectivesThe purpose of this study was to examine the clinical outcomes with aspirin for primary prevention of CVD after the recent publication of large trials adding >45,000 individuals to the published data. MethodsRandomized controlled trials comparing clinical outcomes with aspirin versus control for primary prevention with follow-up duration of ≥1 year were included. Efficacy outcomes included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), stroke, transient ischemic attack (TIA), and major adverse cardiovascular events. Safety outcomes included major bleeding, intracranial bleeding, fatal bleeding, and major gastrointestinal (GI) bleeding. Random effects DerSimonian-Laird risk ratios (RRs) for outcomes were calculated. ResultsA total of 15 randomized controlled trials including 165,502 participants (aspirin n = 83,529, control n = 81,973) were available for analysis. Compared with control, aspirin was associated with similar all-cause death (RR: 0.97; 95% confidence interval [CI]: 0.93 to 1.01), CV death (RR: 0.93; 95% CI: 0.86 to 1.00), and non-CV death (RR: 0.98; 95% CI: 0.92 to 1.05), but a lower risk of nonfatal MI (RR: 0.82; 95% CI: 0.72 to 0.94), TIA (RR: 0.79; 95% CI: 0.71 to 0.89), and ischemic stroke (RR: 0.87; 95% CI: 0.79 to 0.95). Aspirin was associated with a higher risk of major bleeding (RR: 1.5; 95% CI: 1.33 to 1.69), intracranial bleeding (RR: 1.32; 95% CI: 1.12 to 1.55), and major GI bleeding (RR: 1.52; 95% CI: 1.34 to 1.73), with similar rates of fatal bleeding (RR: 1.09; 95% CI: 0.78 to 1.55) compared with the control subjects. Total cancer and cancer-related deaths were similar in both groups within the follow-up period of the study. ConclusionsAspirin for primary prevention reduces nonfatal ischemic events but significantly increases nonfatal bleeding events.

IP091. Impact of Sex on Carotid Artery Stenting Outcomes Among Octogenarians

Carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in CAS outcomes based on published randomized control trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after CAS performed in octogenarians. The National Surgical Quality Improvement Program vascular-targeted data file was queried for all patients 80 years of age and older who underwent CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack (TIA), or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke, TIA, death, and/or myocardial infarction (MI). Outcomes were compared for males versus females and stratified by symptomatic status using univariable and multivariate logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device. Overall, there were 143 octogenarian patients who underwent CAS over the study period, including 95 males (66.4%) and 48 females (33.6%). Median age was 83.9 years (range, 80-90 years), 85.3% were white, and 30.3% were symptomatic. One-third (37.1%) had anatomic high-risk criteria for CEA, while the remainder (62.9%) had high-risk medical comorbidities. Periprocedural stroke/TIA/death/myocardial infarction occurred in 10 males (10.5%) versus 5 females (10.4%; P = .98), and did not significantly differ according to symptomatic versus asymptomatic status (11.6% vs 10.0%; P = .77). Based on multivariable analysis, independent factors associated with a poor periprocedural outcome included emergent versus elective status (adjusted odds ratio [aOR], 21.3; 95% confidence interval [CI], 2.74-165.39) and failure to use an embolic protection device (aOR 4.39; 95% CI, 1.20-16.00). Sex was not associated with the primary outcome after risk adjustment (aOR 0.8; 95% CI, 0.21-2.99). Contrary to prior findings suggesting worse post-CAS outcomes among females, we found no sex-based differences in risk of perioperative stroke, TIA, death, or myocardial infarction among patients 80 years of age and older undergoing CAS. Our study validates previous studies showing a high rate of perioperative complications following CAS in an older population, and reinforces the importance of patient selection and use of an embolic protection device to reduce poor outcomes.

LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures &amp;amp; Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated meta-analysis of randomized trials.

BACKGROUNDA few randomized clinical trials (RCT) and their meta-analyses have found patent foramen ovale closure (PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.AIMTo evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.METHODSElectronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke (IS), transient ischemic attack (TIA), a composite of IS, TIA and systemic embolism (SE), mortality, major bleeding, atrial fibrillation (AF) and procedural complications were the major outcomes. Random-effects model was used to perform analyses.RESULTSMeta-analysis of 6 RCTs including 3560 patients showed that the PFOC, compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95% confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55 (0.32-0.93); P = 0.02] and increased the AF risk [4.79 (2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86 (0.54-1.38); P = 0.54], mortality [0.74 (0.28-1.93); P = 0.53] and major bleeding [0.81 (0.42-1.56); P = 0.53] between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.CONCLUSIONIn certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.

Stroke and thromboembolic events in men with prostate cancer treated with definitive radiation therapy with or without androgen deprivation therapy.

There is conflicting evidence regarding the association between androgen deprivation therapy (ADT) for prostate cancer (PC) and the risk of developing stroke and thromboembolic events. Our study evaluated the association between ADT use and development of stroke, transient ischemic attack (TIA), deep vein thrombosis (DVT), and pulmonary embolism (PE) in a homogenous group of men with PC treated with definitive radiation therapy (RT) after controlling for multiple sources of confounding. Observational cohort study of patients diagnosed with PC at the US Department of Veterans Affairs between 1 January 2001 and October 31, 2015 and treated with definitive RT. Exposure was initiation of ADT within 1 year of PC diagnosis. Primary outcomes were development of stroke, TIA, DVT, or PE. 44,246 men with median follow-up of 6.8 years. The overall cumulative incidences of stroke, TIA, DVT, and PE at 10 years were 6.0, 3.0, 3.4, and 1.9%, respectively. In the multivariable competing risks model, there was a significant association between ADT and stroke (subdistribution hazard ratio (SHR) = 1.19, 95% CI = 1.09-1.30, p < 0.01), TIA (SHR = 1.24, 95% CI = 1.08-1.41, p < 0.01), and DVT (SHR = 1.18, 95% CI = 1.04-1.34, p < 0.01). ADT was only associated with PE in men receiving ADT for > 1 year (SHR = 1.34, 95% CI = 1.06-1.69, p-value = 0.03). We observed an increase in the risk of stroke, TIA, and DVT in men receiving ADT and an increased risk of PE in men receiving long-term ADT. These results highlight concerns regarding long-term risks of ADT on stroke and thromboembolic events in the treatment of PC.

Analysis of Vascular Event Risk After Herpes Zoster From 2007 to 2014 US Insurance Claims Data

ObjectiveTo estimate the risk of transient ischemic attack (TIA), stroke, and myocardial infarction in periods covering 4 weeks before to 52 weeks after herpes zoster (HZ) diagnosis in US adults. Patients and MethodsThis retrospective study (GSK study identifier: HO-15-15771) with matched cohorts used the Truven Health MarketScan Commercial and Medicare claims data set linked with obesity and smoking status information. Patients 18 years and older at the date of HZ diagnosis and 1-year pre- and post-HZ diagnosis continuous insurance enrollment (from January 1, 2007, through December 31, 2014) were propensity score matched to controls in terms of demographic characteristics, risk factors for vascular events, other comorbid disorders, general health, obesity, and smoking status. A post hoc sensitivity analysis was performed not matching for obesity and smoking status information. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson models during an aggregate period (1-month before and after the index date). ResultsA total of 23,339 patients with HZ were matched to 46,378 controls (mean age, 56 years; 45,173 [65%] women). During the aggregate period, patients with HZ were statistically significantly more likely to suffer a TIA: IRRs for all patients and patients aged 18 to 49 years were 1.56 (95% confidence interval [CI], 1.13-2.15) and 5.12 (95% CI, 1.37-19.10), respectively (P<.05); the respective IRRs for stroke were 1.40 (95% CI, 0.93-2.11) and 8.12 (95% CI, 0.93-71.27). In the sensitivity analysis, IRRs for TIA and stroke were statistically significantly increased regardless of age. ConclusionHerpes zoster was associated with an increased risk of composite events, TIA, and stroke in adults in the period around diagnosis. More research on the HZ and vascular risk association is needed. GSK Study IdentifierHO-15-15771

Global Brain Perfusion and the Risk of Transient Ischemic Attack and Ischemic Stroke: The Rotterdam Study.

BackgroundThe role of subtle disturbances of brain perfusion in the risk of transient ischemic attack (TIA) or ischemic stroke remains unknown. We examined the association between global brain perfusion and risk of TIA and ischemic stroke in the general population.Methods and ResultsBetween 2005 and 2015, 5289 stroke‐free participants (mean age, 64.3 years; 55.6% women) from the Rotterdam Study underwent phase‐contrast brain magnetic resonance imaging at baseline to assess global brain perfusion. These participants were followed for incident TIA or ischemic stroke until January 1, 2016. We investigated associations between global brain perfusion (mL of blood flow/100 mL of brain/min) and risk of TIA and ischemic stroke using Cox regression models with adjustment for age, sex, and cardiovascular risk factors. Additionally, we investigated whether associations were modified by retinal vessel calibers, small and large vessel disease, blood pressure, and heart rate. During a median follow‐up of 7.2 years (36 103 person‐years), 137 participants suffered a TIA and another 108 an ischemic stroke. We found that lower global brain perfusion was associated with a higher risk of TIA, but not with the risk of ischemic stroke (adjusted hazard ratio, 95% CI, per standard deviation decrease of global brain perfusion: 1.29, 1.07–1.55 for TIA and adjusted hazard ratio of 1.06, 0.87–1.30 for ischemic stroke). Across strata of wider arteriolar retinal calibers, lower brain perfusion was more prominently associated with TIA, but not with ischemic stroke.ConclusionsIn a community‐dwelling population, impaired global brain perfusion increased the risk of TIA, but not of ischemic stroke.

Abstract TMP94: Oxidized Low-Density Lipoprotein and Low-Density Lipoprotein Have Combined Utility in Predicting Outcomes of Minor Stroke and TIA

Objective: To estimate the association of different combination of circulating LDL and oxLDL levels with the outcomes of acute minor ischemic stroke and transient ischemic attack (TIA). Methods: In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, a subgroup of 3019 patients with elevated baseline oxLDL and LDL levels were analyzed. Patients were divided into four groups according to different combination of LDL and oxLDL levels. The associations of LDL and oxLDL with prognosis of patients using multivariable Cox regression models. Results: Among 3019 patients included in this study, the median (interquartile range) of oxLDL, and LDL were 13.96 (6.65-28.81) ug/dL, 3.1(2.5-3.8) mmol/L, respectively. Compared with those with low LDL and oxLDL levels (LDL &lt; 3.37mmol/L with oxLDL &lt;13.96 ug/dL), patients with conformably high levels of LDL and oxLDL (LDL ≥3.37mmol/L , oxLDL ≥13.96 ug/dL) were associated with an increased risk of recurrent stroke at 90 days(HR,1.88; 95% CI,1.37-2.57)) and 1 year (HR,1.71; 95% CI,1.29-2.27). Neither elevated level of oxLDL or LDL increased alone showed statistical significance. Similar results were observed for poor functional outcome. Conclusions: Presence of both elevated oxLDL and LDL levels can predict an increased risk of recurrent stroke and poor functional outcome in minor stroke or high- risk TIA patients. The presence of both oxLDL and LDL might have a combined effect.

A systematic review and meta-regression analysis to examine the ‘timing hypothesis’ of hormone replacement therapy on mortality, coronary heart disease, and stroke

BackgroundThe ‘Timing Hypothesis’ states that the benefits and harms of hormone replacement therapy (HRT) are related to the proximity with which it is begun following the onset of menopause. The primary aim of this analysis was to test for heterogeneity of treatment effect for HRT using Chi2 and I2 tests for younger versus older initiators of HRT. The secondary aim was to perform a meta-regression with mean age at trial baseline as the covariate for various outcomes. MethodsYounger initiation trials were defined as those with mean age of participants <60 years and older initiation trials were those with mean age >60 years. The primary endpoints included all-cause mortality, cardiac mortality, coronary heart disease (CHD) events (a composite of cardiac mortality and nonfatal myocardial (MI)), and a composite of stroke, transient ischemic attack (TIA) and systemic embolism. ResultsThirty-one RCTs were identified comparing HRT users to nonusers (n = 40,521). There was significant heterogeneity of treatment effect between younger versus older HRT initiators for all-cause mortality (Chi2 = 9.74, p = 0.002, I2 = 89.7%), cardiac mortality (Chi2 = 4.04, p = 0.04, I2 = 75.2%), and CHD events (Chi2 = 3.06, p = 0.08, I2 = 67.3%). Both groups experienced an increase in stroke, TIA and systemic embolism (1112/18,774 in the HRT group versus 734/18,070 in the control group; OR = 1.52; 95% confidence interval (CI) = 1.38–1.67). When performing the meta-regression, as age increased the treatment effect of HRT was increased for stroke, TIA and systemic embolism (point estimate 0.006 with a standard error of 0.002) (p = 0.0003). ConclusionYounger initiation of HRT may be effective in reducing death and cardiac events. However, younger HRT initiators remained at an increased risk of stroke, TIA and systemic embolism and this risk increased as average age increased. Younger menopausal women using HRT to treat vasomotor symptoms do not appear to be at an increased risk of dying or experiencing CHD events.

Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis

ObjectiveTo assess the effectiveness and safety of dual agent antiplatelet therapy combining clopidogrel and aspirin to prevent recurrent thrombotic and bleeding events compared with aspirin alone in patients with acute...

Electrical isolation of the left atrial appendage increases the risk of ischemic stroke and transient ischemic attack regardless of postisolation flow velocity

Electrical isolation of the left atrial appendage (LAA) is associated with a lower rate of atrial fibrillation (AF) recurrence in patients undergoing radiofrequency catheter ablation. However, LAA isolation can significantly impair LAA contractility. This study was performed to evaluate whether electrical isolation of the LAA is associated with an increased risk of ischemic stroke or transient ischemic attack (TIA). Consecutive patients with AF undergoing radiofrequency catheter ablation at Korea University Medical Center Anam Hospital were analyzed. Of 2352 patients, 39 (1.7%) had LAA isolation. Patients with LAA isolation had a significantly higher rate of ischemic stroke or TIA than did those without LAA isolation (log-rank, P < .001; hazard ratio 23.6; P < .001). There were significant differences in the baseline characteristics of the 2 groups, including type of AF (34 [87.2%] and 911 [39.4%] patients with and without LAA isolation had nonparoxysmal AF, respectively). After multivariate adjustment, LAA isolation was found to be a significant risk factor for ischemic stroke or TIA (adjusted hazard ratio 11.3; P < .001). Propensity score-matched analysis also revealed an increased risk of ischemic stroke or TIA in patients with LAA isolation compared with those without LAA isolation (log-rank, P = .001). The LAA flow velocity of post-LAA isolation status was not significantly different between patients who did and did not experience ischemic stroke or TIA (30.3 ± 17.7 cm/s vs 33.9 ± 17.9 cm/s; P = .608). A significantly increased risk of ischemic stroke or TIA was observed in patients with electrical isolation of the LAA. In addition, postisolation LAA flow velocity is not a reliable marker to predict future ischemic events.

Occupational and leisure-time physical activity differentially predict 6-year incidence of stroke and transient ischemic attack in women.

Objectives Recent meta-analyses suggest a physical activity health paradox: high levels of occupational physical activity (OPA) increase cardiovascular disease (CVD) risk, while leisure-time physical activity (LTPA) decreases risk. However, studies of women and cerebrovascular disease are limited. This report examines physical activity effects on stroke and transient ischemic attack (TIA) among working women in the United States. Methods OPA history, health status, and lifestyle were assessed by baseline interviews of 31 270 employed Sister Study participants aged 35-74 years. OPA was assessed at six intensity levels (lowest: "mostly sitting"); the highest three were combined as "high intensity work." Independent OPA and LTPA effects on 6-year cerebrovascular disease incidence were estimated in adjusted Cox proportional hazard models. Results Stroke (N=441) and TIA (N=274) risk increased with more standing and higher intensity work at current and longest held job. Compared with mostly sitting, high intensity work at the current job increased TIA risk by 57% [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.04-2.38]. High intensity OPA at the longest held job increased risk for stroke by 44% (HR 1.44; 95% CI 1.08-1.93). Among women with CVD, sitting and standing equally, especially at the current job, increased risks up to two-fold (TIA HR 1.98, 95% CI 1.10-3.55) compared with mostly sitting at work. LTPA showed inverse associations. Conclusions Higher intensity levels of OPA increased stroke and TIA risks, while LTPA decreased risks; results corroborate the physical activity health paradox for women and cerebrovascular disease. More standing at work increased cerebrovascular disease risks, especially for women with CVD.

Abstract 17143: An Updated Meta Analysis Comparingtranscatheterpatent Foramen Ovale Closure versus Medical Therapy to Prevent Recurrent Cryptogenic Stroke

Background: The closure of patent foramen ovale (PFO) by percutaneous transcatheter approach is controversial in a patient with cryptogenic stroke. Here in, we reviewed the literature and analyzed the data on safety and efficacy of standard medical therapy (MT) compared to mechanical closure by the percutaneous trans-catheter approach after recently published DEFENSE-PFO trial. Hypothesis: Transcatheter PFO closure decreases incidence of recurrent stroke compared to standard MT. Methods: We systematically searched PubMed, SCOPUS and EMBASE for the articles that compared overall mortality, efficacy in preventing recurrent stroke, and transient ischemic attack (TIA) after transcatheter PFO closure compared to standard MT. We also evaluated potential complications such as bleeding and development of atrial fibrillation. Results: A total 6 studies with 3,403 patients met pre-defined inclusion criteria. Mean follow-up was 3.75 years. Overall mortality was indifferent between transcatheter closure compared to MT (RR: 0.74, 95% CI 0.35-1.6, P=0.45, I 2= 0%). However, PFO closure reduced the rate of recurrent stroke by at least 60% (RR: 0.39, 95% CI 0.18-0.82, P=0.01, I 2= 56%), while did not reduce the risk of TIA compared to MT (RR: 0.76, 95% CI 0.52-1.12, P= 0.17, I 2 =0%). Higher incidence of atrial fibrillation was evident in mechanical closure (RR: 4.64, 95% CI 2.37-9.09, p&lt;0.00001, I 2 =11%) but no increase in bleeding (RR: 0.88, 95% CI: 0.4-1.93, p=0.74, I 2 =28%). Conclusions: Mechanical PFO closure by transcatheter approach is a viable option in the prevention of recurrent stroke and TIA with an increased risk of development of atrial fibrillation without the risk of bleeding.

ED Referral Dramatically Reduces Delays of Initial Evaluation in a French TIA Clinic.

Background: The risk of recurrent brain infarction (BI) is high within the first hours after a transient ischemic attack (TIA). Emergent, specialized, and tailored patient management in a TIA program reduces the risk of recurrent BI after TIA by 80%. New antithrombotic strategies have been successfully tested within 12 h after TIA onset. We aim to investigate the factors associated with a delay of more than 12 h from TIA onset to evaluation in our TIA clinic.Methods: In consecutive patients evaluated in our TIA clinic from 01/2012 to 11/2013, we prospectively collected delays from onset to arrival, baseline characteristics, discharge diagnosis and recurrent BI at 1 week. Referring pathways were dichotomized between office-based physicians (OBP) and emergency departments (ED). Univariate and multivariate logistic regression were performed.Results: 354 patients were evaluated. Mean (+/– SD) age was 61 years (+/−18). Median (IQR) ABCD2 score was 3 (2–4). Median (IQR) delay from onset to evaluation was 8 h (4–48). Overall, 185 (52%) were referred by OBP vs. 169 (48%) by ED. Evaluation was initiated within 12 h among 201 (57%) patients. After logistic regression, OBP referral was by comparison with ED the only independent factor associated with an evaluation delay >12 h (OR 5.7, 95% CI: 3.5–9.3, p < 0.0001).Conclusion: Our results suggest that preliminary assessment by OBP may increase the delay to initiate the emergent evaluation of TIA patients. Promoting direct admission to TIA clinics through ED may be an efficient alternative for high risk TIAs.

Comparison of Frequency of Ischemic Stroke in Patients With Versus Without Coronary Heart Disease and Without Atrial Fibrillation

Recent trials of antithrombotic therapy in patients with coronary artery disease (CAD) have demonstrated substantial reductions in ischemic stroke. Our aim was to examine ischemic stroke risk in patients with CAD and to identify those at highest risk. We examined ischemic stroke risk in patients without atrial fibrillation who underwent coronary angiography between 2004 and 2012. Patients were stratified according to presence or absence of CAD and further stratified by extent of CAD (0 vessel disease [VD], 1 VD, 2 VD, 3 VD, and diffuse VD). End points were composites of ischemic stroke, transient ischemic attack (TIA), and systemic embolism, as well as major adverse cardiovascular and cerebrovascular events (MACCE) defined as cardiac death, myocardial infarction, plus ischemic stroke, TIA, and systemic embolism. Adjusted incidence rate ratios (IRRs) were estimated. A total of 68,829 patients were included, 25,032 had 0 VD, 4,736 had diffuse VD, 18,471 had 1 VD, 10,588 had 2 VD, and 10,002 had 3 VD. Median follow-up was 4.0 years. CAD extent was associated with an increased risk of stroke, TIA, and systemic embolism (1 VD: adjusted IRR 1.02, 95% confidence interval [CI] 0.90 to 1.16; diffuse VD: adjusted IRR 1.22, 95% CI 1.02 to 1.47; 2 VD: adjusted IRR 1.28, 95% CI 1.12 to 1.45; 3 VD: adjusted IRR 1.37, 95% CI 1.20 to 1.55) compared with patients with 0 VD. Presence and extent of CAD were also associated with MACCE. In conclusion, CAD is associated with an increased risk of stroke, TIA, and systemic embolism and MACCE in patients without atrial fibrillation, and patients with coronary multi-VD are at highest risk and may be candidates for treatment strategies aiming at reducing ischemic stroke incidence.

Percutaneous Closure of Patent Foramen Ovale in Patients with Cryptogenic Stroke - An Updated Comprehensive Meta-Analysis.

The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone. PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance. A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33-0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52-1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33-1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06-11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55-1.57, p = 0.78). The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

Risk of stroke and transient ischaemic attack in patients with a diagnosis of resolved atrial fibrillation: retrospective cohort studies

ObjectivesTo determine rates of stroke or transient ischaemic attack (TIA) and all cause mortality in patients with a diagnosis of “resolved” atrial fibrillation compared to patients with unresolved atrial fibrillation...