Treatment For Stroke Prevention Research Articles

Viral Infection and Ischemic Stroke: Emerging Trends and Mechanistic Insights.

Population studies have suggested that viral infections may be contributing to risk of ischemic stroke, although the mechanisms for this are unclear. In this review, we examine the epidemiological evidence supporting the involvement of viral diseases, including influenza, COVID-19, chronic herpesvirus infections, and hepatitis C in current trends of stroke incidence. To support these associations, we highlight the virus-host interactions that are critical in the context of stroke, including direct effects of acute and persistent viral infections on vascular function, inflammation, and thrombosis. Additionally, we evaluate the systemic changes that occur during viral infection that can predispose individuals to ischemic stroke, including alterations in blood pressure regulation, coagulation, and lipid metabolism. Our review emphasizes the need to further elucidate precise mechanisms involved in viral infections and stroke risk. Future research will inform the development of targeted interventions for stroke prevention in the context of viral diseases.

Watchman vs. Amulet for Left Atrial Appendage Closure: Current Evidence and Future Perspectives.

Left atrial appendage closure (LAAC) is a crucial intervention for stroke prevention in patients with non-valvular atrial fibrillation who are unsuitable for long-term anticoagulation. Amulet and Watchman are the most implanted devices worldwide for performing LAAC, and the aim of this review is to provide a comprehensive comparison focusing on their efficacy, safety, and short- and long-term outcomes. The Watchman device, the first to gain FDA approval, has been extensively studied and demonstrates significant reductions in stroke and systemic embolism rates. The Amulet device, a newer alternative, promises enhanced design features for more efficient appendage sealing. Current data highlight that both devices offer similar efficacy and safety for LAAC. While the two devices differ in terms of intraprocedural complication rates, they offer similar short- to long-term outcomes in terms of peri-device leaks, device-related thrombosis, and mortality. Both devices are indicated for patients who are unable to tolerate OAC, given their similar risk and safety profiles. Newer clinical studies are directed at establishing the efficacy of both devices as the primary method for stroke prevention in AF as an alternative to OAC.

Tea and coffee consumption and risk of acute stroke: The INTERSTROKE Study.

Stroke is a leading global cause of death and disability. Daily tea/coffee intake is consumed by > 50% of populations and may represent an important population-level exposure. Therefore, it is first essential that we better understand the associations between the tea/coffee intake and stroke. This research aims to generate hypotheses about the global associations between tea and coffee intake and stroke. These insights will identify interventions for stroke prevention that can be further explored using alternative study designs. INTERSTROKE is a large international matched case-control study of first stroke from 32 countries. Participants were asked "how many cups do you drink each day?" of coffee, green tea, black tea, and other tea. Multivariable conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between intake and stroke. We included 13,462 cases and 13,488 controls from INTERSTROKE; mean age was 61.7 (13.4) years and 59.6% (n = 16,010) were male. Overall, 19.4% (n = 5239) did not consume tea/coffee, 47.0% (n = 12,666) consumed tea only, 14.9% (n = 4024) consumed coffee alone, and 18.6% (n = 5021) consumed both, with significant regional variations. After multivariable adjustment, there was no association between low/moderate coffee intake and stroke, but high consumption (> 4/day) was associated with higher odds of all stroke (OR = 1.37 (95% CI = 1.06-1.77)) or ischemic stroke (OR = 1.32 (95% CI = 1.00-1.74)). Tea consumption was associated with lower odds of all (OR = 0.81 (95% CI = 0.69-0.94) for highest intake) or ischemic stroke (OR = 0.81 (95% CI = 0.68-0.98) for highest intake). High coffee consumption was associated with higher odds of all or ischemic stroke; low-moderate coffee had no association with stroke. In contrast, tea consumption was associated with lower odds of stroke. These associations suggest that individuals consider avoiding high coffee consumption (⩾ five cups/day) to impact future stroke risk. The design and rationale of INTERSTROKE was published previously. Individual participant data, or other documents are not available.

Clinical effects of acupuncture treatment for prevention of insomnia-induced stroke: A large-scale cohort study

BackgroundRecent research has established an association between insomnia and an elevated risk of stroke. Given the severe global impact of stroke on public health, exploring nonpharmacological interventions, such as acupuncture, that can mitigate stroke risk among individuals with insomnia is crucial. MethodsIn this retrospective cohort study, we used data from the Taiwan National Health Insurance Database (NHIRD) to examine the relationship between acupuncture and the risk of stroke among individuals who received a diagnosis of insomnia between 2000 and 2017. The study participants were divided into two cohorts: the acupuncture group that received acupuncture and a matched control group that did not. The primary outcome was the occurrence of stroke. ResultsOf the 217,356 patients included in the study, 3668 individuals in the acupuncture group and 4913 in the control group experienced stroke. The incidence rate of stroke was lower in the acupuncture group (4.51 per 1000 person-years) than in the control group (6.86 per 1000 person-years). After adjustment for various potential confounders, patients who received acupuncture exhibited a notably reduced risk of stroke, with an adjusted hazard ratio of 0.66 (95 % confidence interval [CI]: 0.63, 0.69). Furthermore, a dose–response relationship was evident, in that individuals who received 6–11 acupuncture sessions experienced a 24 % reduction in stroke risk, whereas those who received 12–17 sessions, 18–29 sessions, and ≥30 sessions exhibited reductions of 31 %, 34 %, and 42 %, respectively. ConclusionAcupuncture treatment was significantly associated with a reduced risk of stroke among patients with insomnia.

Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association.

The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial. STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care. Clinicaltrials.gov, NCT04396418.

PCR96 Exploring Patient Preferences through Cross-Sectional Discrete Choice Experiment: An Insight into Once-Daily Stroke Prevention Treatments in Atrial Fibrillation in Asia

PCR96 Exploring Patient Preferences through Cross-Sectional Discrete Choice Experiment: An Insight into Once-Daily Stroke Prevention Treatments in Atrial Fibrillation in Asia

Impact of different dose reduction criteria on dose assignment of current DOACs and related outcomes: an analysis from 4-year data of the ETNA-AF Europe programme

Abstract Background Direct oral anticoagulants (DOACs) are the standard treatment for stroke prevention in patients with atrial fibrillation (AF). Pharmacological characteristics and dose reduction criteria of the four currently available DOACs are different. Several studies have reported frequent use of non-recommended doses of DOACs associated with worse clinical outcomes. Data from real-world studies, such as the edoxaban Treatment in routiNe clinical prActice (ETNA)-AF, may help assessing the size of this phenomenon and its impact on clinical outcomes. Purpose To evaluate the distribution of dose reduction criteria and explore associated outcomes in a large, unselected, real-world population using 4-year data from the ETNA-AF EU study. Methods The ETNA-AF EU is a prospective, observational, study to evaluate safety and effectiveness of edoxaban in patients with AF from Europe. Patients with available data regarding the SmPC dose reduction criteria of the four currently available DOACs were included. Patients with a creatinine clearance <30 mL/min were excluded. Patients were classified by dose reduction criteria for the different DOACs (i.e., full dose for all [FULL], reduced dose for all [REDUCED], patients not included in previous groups [INTERMEDIATE]). Results We included 12,866 patients from the ETNA-AF EU study. According to the SmPC dose reduction criteria, the percentage of patients that would be eligible for a dose reduction in the ETNA population was highly heterogenous across different DOACS: 5.7% for apixaban, 16.8% for rivaroxaban, 23.8% for edoxaban and 52.9% for dabigatran. Moreover, differences in the dose reduction criteria included in each SmPC was reflected by the distribution of patients in the three pre-specified groups. Among the 11,003 assignable patients, 42.4% would receive a full dose, 5.1% would receive a reduced dose and the largest percentage, 52.5%, was in the INTERMEDIATE group, which would receive either a full or reduced dose of any DOAC depending on the selected agent. Of the patients included in the INTERMEDIATE group, 65.2% received a full dose of edoxaban due to its specific labelling. Interestingly, the INTERMEDIATE group included the vast majority of patients known to be at risk of adverse events: very elderly (i.e., ≥85 yrs; 76.5%), frail as per investigator (73.3%), history of previous stroke (60.4%) or history of bleeding (61.3%). Clinical outcomes at four years were significantly higher in both the INTERMEDIATE and the REDUCED groups compared to the FULL group, with the only exception of haemorrhagic stroke (Table). Conclusion(s): According to the different dose reduction criteria of currently available DOACs, notable percentage of patients could receive either a full or a reduced dose depending on the DOAC chosen by the physician. Considering that the chosen dose of the DOAC has an impact on clinical outcomes, patients in the INTERMEDIATE group need careful assessment, which warrants further analysis.

Acute haemodynamic changes during left atrial appendage closure

Abstract Purpose Left atrial appendage closure (LAAC) presents an alternative treatment for stroke prevention in atrial fibrillation (AF) in patients with contraindication for long-term anticoagulation. However, even in patients in AF, left atrial appendage plays an important role in reservoir function of left atrium. The purpose of this study was to assess acute hemodynamic effects during LAAC. Methods Consecutive patients indicated for LAAC from January 2022 to October 2023 were enrolled. The invasive hemodynamic measurements were done at the beginning of the procedure after transseptal puncture, and at the end from the procedure after device deployment. Following parameters were measured: systolic, and diastolic blood pressure, and pressure in left atrium (LA), all measurements were done at rest and after 3 minute isometric exercise (handgrip). Results Thirty-two patients were included (age 76,2+7,1 yrs, 22 (69%) males, 23 (72%) permanent AF, left ventricular ejection fraction 52+11,8%). No patients experienced moderate/severe mitral insufficiency, the saline intake during procedure was 738 ml. Isometric exercise significantly increased the LA pressure: the LA pressures (rest/exercise) were 13.7+6.7 mmHg/16.7+8.8 mmHg (p=0.003) at the beginning of the procedure, and 17.0+7.3mmHg/20.0+7.3 mmHg (p=0.005) after device deployment. The LA pressure obtained after device deployment (both rest/exercise) were significantly higher compared to values obtained at the beginning of the procedure. (p=0.003). Conclusions LAAC is associated acute increase of both rest and exercise LA pressure. Whether its acute negative effect remains over time needs further investigation.

Frequency of and factors associated with underdosing of direct oral anticoagulants in patients with ischaemic stroke and atrial fibrillation

IntroductionDirect oral anticoagulants (DOACs) are the first line of stroke prevention treatment in patients with non-valvular atrial fibrillation (NVAF). However, their inappropriate use is associated with increased risk of stroke, haemorrhagic complications, and mortality. The aim of this study is to analyse the factors associated with the non-prescription of anticoagulants and the underdosing of DOACs. MethodsWe conducted a descriptive study of a prospective registry of patients admitted to a stroke unit due to ischaemic stroke or transient ischaemic attack (TIA) during an 1-year period. We included consecutive patients with history of NVAF with indication for anticoagulant therapy (ACT), according to the CHA2DS2-VASc scale. We analysed demographic factors, exposure to vascular risk factors, kidney function, polymedication, and short- and medium-term stroke progression. ResultsData were obtained from 60 patients admitted due to TIA or ischaemic stroke, with a previous diagnosis of NVAF, of whom 13 (21.7%) were not receiving ACT. Of the remaining 47, 25 (53.2%) were under treatment with DOACs, 21 (44.7%) with vitamin K antagonists, and 1 (2.1%) with heparin. Among patients on DOACs, 8 (32%) were receiving inappropriately low doses, with no differences between drugs.Age (80.8 vs 74.9 years, p=.05) and female sex (75% vs 35.3%, p=.05) were associated with underdosing of DOACs. Paroxysmal atrial fibrillation (46.2% vs 14.9%, p<.005) and antiplatelet therapy (61.5% vs 8.5%, p<.005) were associated with non-prescription of ACT. ConclusionsInappropriate use of ACT, including underdosing, is frequent in our setting, occurring in up to one-third of patients admitted due to ischaemic stroke.

Acute severe renal failure in a patient receiving apixaban: a case report

Because there is little clinical experience with apixaban in patients with severe renal impairment and non-valvular atrial fibrillation, the European Medicines Agency does not advise using it to prevent strokes in these patients. However, only a small number of pharmacokinetic and pharmacodynamic investigations showed how crucially different elimination pathways contribute to the clearance of apixaban. A 74-year-old male patient who was receiving apixaban treatment for stroke prevention in atrial fibrillation was referred to our hospital because of acute severe renal failure brought on by dehydration and abnormally elevated apixaban plasma levels. The patient was treated only with intravenous fluid therapy; serum creatinine recovered slowly over the course of six days, but plasma apixaban levels recovered quickly. No bleeding events have been recorded. Our experience demonstrates the safety profile of apixaban in cases of severe renal failure, but it also emphasizes the need for more research to confirm this evidence.

Magnitude of Effect of Low Dose Colchicine, a Newly FDA Approved Treatment for Stroke Prevention (P10-5.003)

Magnitude of Effect of Low Dose Colchicine, a Newly FDA Approved Treatment for Stroke Prevention (P10-5.003)

MRI in the Evaluation of Cryptogenic Stroke and Embolic Stroke of Undetermined Source.

Cryptogenic stroke refers to a stroke of undetermined etiology. It accounts for approximately one-fifth of ischemic strokes and has a higher prevalence in younger patients. Embolic stroke of undetermined source (ESUS) refers to a subgroup of patients with nonlacunar cryptogenic strokes in whom embolism is the suspected stroke mechanism. Under the classifications of cryptogenic stroke or ESUS, there is wide heterogeneity in possible stroke mechanisms. In the absence of a confirmed stroke etiology, there is no established treatment for secondary prevention of stroke in patients experiencing cryptogenic stroke or ESUS, despite several clinical trials, leaving physicians with a clinical dilemma. Both conventional and advanced MRI techniques are available in clinical practice to identify differentiating features and stroke patterns and to determine or infer the underlying etiologic cause, such as atherosclerotic plaques and cardiogenic or paradoxical embolism due to occult pelvic venous thrombi. The aim of this review is to highlight the diagnostic utility of various MRI techniques in patients with cryptogenic stroke or ESUS. Future trends in technological advancement for promoting the adoption of MRI in such a special clinical application are also discussed.

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

A real-world multicenter study on left atrial appendage occlusion: The Italian multi-device experience

BackgroundTranscatheter left atrial appendage occlusion (LAAO) has emerged as an alternative treatment for stroke prevention in patients with atrial fibrillation (AF) at high risk of thromboembolism, who cannot tolerate long-term oral anticoagulation (OAC). Questions persist regarding effectiveness and safety of this treatment and the optimal post-interventional antithrombotic regimen after LAAO. MethodsWe retrospectively gathered data from 428 patients who underwent percutaneous LAAO in 6 Italian high-volume centres, aimed at describing the real-world utilization, safety, and effectiveness of LAAO procedures, also assessing the clinical outcomes associated with different antithrombotic strategies. ResultsAmong the entire population, 20 (4.7 %) patients experienced a combination of pericardial effusion and periprocedural major bleeding: 8 (1.9 %) pericardial effusion, 1 (0.3 %) fatal bleeding, and 3 (0.7 %) non-fatal procedural major bleeding. Patients were discharged with different antithrombotic regimens: dual (DAPT) (27 %) or single (SAPT) (26 %) antiplatelet therapy, OAC (27 %), other antithrombotic regimens (14 %). Very few patients were not prescribed with antithrombotic drugs (6 %). At a medium 523 ± 58 days follow-up, 14 patients (3.3 %) experienced all-cause death, 6 patients (1.4 %) cardiovascular death, 3 patients (0.7 %) major bleeding, 10 patients (2.6 %) clinically relevant non-major bleeding, and 3 patients (0.7 %) ischemic stroke. At survival analysis, with DAPT as the reference group, OAC therapy was associated with better outcomes. ConclusionsOur findings confirm that LAAO is a safe procedure. Different individualized post-discharge antithrombotic regimens are now adopted, likely driven by the perceived thrombotic and hemorrhagic risk. The incidence of both ischemic and bleeding events tends to be low.

Drug-Drug Interactions of FXI Inhibitors: Clinical Relevance.

Inhibitors of the factor FXI represent a new class of anticoagulant agents that are facing clinical approval for the treatment of acute coronary syndrome (ACS), venous thromboembolism (VTE), and stroke prevention of atrial fibrillation (AF). These new inhibitors include chemical small molecules (asundexian and milvexian), monoclonal antibodies (abelacimab, osocimab, and xisomab), and antisense oligonucleotides (IONIS-FXIRX and fesomersen), and thus, they have very peculiar and different pharmacokinetic and pharmacodynamic properties. Besides their clinical efficacy and safety, based on their pharmacological heterogeneity, the use of these drugs in patients with comorbidities may undergo drug-drug interactions (DDIs) with other concomitant therapies. Although only little clinical evidence is available, it is possible to predict clinically relevant DDI by taking into consideration their pharmacokinetic properties, such as the CYP450-dependent metabolism, the interaction with drug transporters, and/or the route of elimination. These characteristics may be useful to differentiate their use with the direct oral anticoagulant (DOAC) anti -FXa (rivaroxaban, apixaban, edoxaban) and thrombin (dabigatran), whose pharmacokinetics are strongly dependent from P-gp inhibitors/inducers. In the present review, we summarize the current clinical evidence on DDIs of new anti FXI with CYP450/P-gp inhibitors and inducers and indicate potential differences with DOAC anti FXa.

The Safety and Effectiveness of Apixaban in Patients with End-Stage Kidney Disease on Dialysis: A Retrospective Observational Study.

Background: Apixaban has been increasingly utilized for various FDA-approved indications, including stroke prevention and venous thromboembolism (VTE) treatment in patients with end stage kidney disease (ESKD) on hemodialysis. However, the safety and efficacy of its use in this population is not well established. Hence, the purpose of this study is to evaluate the safety and effectiveness of apixaban by examining outcomes in this population. Methods: This was a retrospective observational study that involved adults with ESKD who were on hemodialysis and prescribed apixaban from our hospital's outpatient pharmacy between 1 May 2015, and 31 March 2022. Demographics, apixaban indications, dose appropriateness, concomitant antiplatelet use, and comorbidities data were collected. Bleeding and thromboembolic events were also collected. Results: Sixty-six patients fulfilled the inclusion criteria, 50% of them males. Median age was 71 (63.5-82) years, and the median BMI 28.2 (59.5-86.25) kg/m2. The median follow-up time was 5 (1.9-12.3) months. Concomitant antiplatelet use (39.4%) and high medication adherence (84.8%) were observed. During follow-up, major bleeding events occurred in 15.2% of cases, with minor bleeding being more common (36.4%), and VTE and stroke events occurred in 4.5% of cases; appropriate dosing was prevalent (62.1%), and there was an overall all-cause mortality rate of 34.8%. Most patients received a 2.5 mg BID apixaban dose (56.1%), including both NVAF and VTE groups. Notably, the multivariate logistic regression analysis indicated that weight, and daily dose were insignificant predictors of bleeding events (p = 0.104, 0.591), however, the BMI was the main independent risk factor for bleeding in this population [OR = 0.9, 95% CI: 0.8-0.99; p = 0.023]. Conclusions: Our analysis of apixaban-treated ESKD patients highlights that the risk of bleeding is significant, and BMI was the main independent risk factor. A larger prospective study is needed to confirm our findings.

Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes.

Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.

Abstract TP266: Utilization of Survey, Focus Group, and Referral Data to Plan a Targeted Intervention for Rural Stroke Disparities, Prevention, and Care Access

Methods: This project was a collaborative partnership between a healthcare organization, academic institute, and the local Faith Health Network. A 34-question survey (n=54 respondents) collected data on rural community knowledge of stroke risk factors, symptoms, and prevention. Three focus groups (n=40 total participants) were conducted to better understand experiences with stroke and obstacles to accessing wellness and healthcare in rural communities. The focus group questions centered on barriers, stroke impact, and solutions. Thematic summaries were aligned with stroke referral heat maps and demographics to develop a targeted plan for intervention. Results: Survey respondents reported gaps in awareness of stroke risk factors, stroke identification, and emergency response. Lack of motivation, followed by lack of time or energy, stress, lack of access to healthy foods, and community of support were barriers to healthy living. Cost, followed by transportation, access to medications, time, lack of insurance, and language differences were barriers to accessing medical care. Thematic analysis of focus group discussions was conducted for the three initial topics of barriers, stroke impact, and solutions. Dialogue on barriers revealed themes of lifestyle, access, and advocacy. Themes within stroke impact included mental health, access, and advocacy. For solutions, themes emerged as health education, lifestyle, access, and advocacy. Each theme had additional subthemes and direct participant quotes. Survey responses, focus group themes, and referral demographics were synthesized to form a plan to impact stroke prevention and care in these rural areas. Conclusion: A multi-faceted, targeted approach is necessary to increase rural stroke awareness, address disparities in care, and decrease barriers to healthy living and care access.

Stroke prevention strategies in Africa: a scoping review protocol.

The objective of this scoping review is to map the existing strategies on methods and interventions for primary and secondary stroke prevention in Africa. Stroke is among the leading causes of disability globally. African nations have higher stroke mortality and case fatality rates than the industrialized world, leading to significant social and financial costs, which necessitates efficient preventative methods. Despite the high prevalence of stroke in Africa, the scope of stroke-prevention strategies in Africa is unknown. Consequently, mapping diverse approaches to preventing stroke in Africa could provide direction for future research into stroke prevention in Africa. This review will incorporate studies that report methods or strategies used for stroke prevention in Africa. All primary and gray literature will be considered for inclusion. No language or date restrictions will be applied. The JBI methodological framework for scoping reviews will be adopted for this scoping review. A 3-step search strategy consisting of an initial limited search, a full search, and a screening of the reference lists of all included articles will be undertaken. Databases such as CINAHL, Scopus, PubMed, PEDRo, DORIS, Global Health, Web of Science, and Open Access Thesis and Dissertations will be searched. All search results will be screened, and relevant data extracted by 2 independent reviewers. The findings will be presented in the final scoping review and illustrated in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Figshare https://doi.org/10.6084/m9.figshare.21679904.v1.

Abstract WP251: Dietary Methionine and Homocysteine Level Interaction and Recurrent Stroke

Background: The folate one-carbon metabolism pathway (FOCM) provides vital one-carbon units for epigenetic regulation. Genetic variants in FOCM genes may affect methionine metabolism. Elevated circulating homocysteine (Hcy), a FOCM byproduct, is linked to increased stroke risk. However, the protective effects of dietary regulation of methionine and Hcy levels against recurrent stroke are uncertain. Objective: To investigate dietary methionine (METH) and its interaction with post-methionine load Hcy levels (POST) with recurrent stroke risk; to assess if genetically determined POST and its interaction with METH predict recurrent stroke risk. Methods: We utilized the Vitamin Intervention for Stroke Prevention (VISP) trial to estimate hazards ratios of METH and its interaction with POST on recurrent stroke with a Cox proportional hazards model. We also generated a POST polygenic risk score (PRS) with ridge regression using previously identified polymorphisms, located within ALDH1L1, CPS1, GNMT, and PSPH, as indicators of FOCM function. Results: The participants (n = 2,100; 64% men) had a mean (SD) age of 67 (11) years. Ancestry consisted of 82% European, 12% African, and 5.7% Other. A small portion of participants had missing POST values (7.3%). Clinical POST (HR 1.02; 95%CI 0.98, 1.06) and its interaction with METH (HR 0.99; 95% CI 0.97, 1.01) were not associated with recurrent stroke risk. Similarly, there was no significant relationship observed between PRS POST (HR 0.96; 95%CI 0.80, 1.15) and its interaction with METH (HR 1.02; 95% CI 0.94, 1.10). Conclusion: Dietary methionine and post-methionine load Hcy levels neither interact nor predict recurrent stroke risk. Our PRS approach showed similar negative findings. The relationship of the FOCM and recurrent stroke risk may lie in epigenetics.