Vascular Events In Patients Research Articles

Serum lipoprotein (a) levels as an independent risk factor for ischemic stroke

Background: Increased plasma concentrations of atherogenic lipoproteins, especially Lp (a) play an important role in the development of atherosclerosis leading to premature myocaridial infarction and stroke. Lp (a) is a novel risk factor for atherosclerosis, whose role in multiracial populations has been debated. The significance of different lipid variables in cardiovascular disease and cerebrovascular disease has been extensively studied but the role of Lp (a) in Indian population is yet to be determined. Objective: To determine the role of Lipoprotein (a) as a marker for ischemic stroke, with regard to Indian scenario. Design: This is a case-control study. Duration: One year (2019-2020). Setting: Department of Medicine, Osmania General Hospital, Hyderabad. Participants: Hundred patients admitted in Osmania General Hospital, Hyderabad. Methods: Diagnosis of ischemic stroke was based on clinical evidence of ischemic stroke and CT scan/MRI. Some exclusions were made. 50 age and sex matched healthy subjects were used as controls. In all patients, a detailed history, general physical examination, a detailed neurological examination and other risk factor variables were entered on a pre-designed proforma. SBP ≥140mm Hg, DBP ≥90mm Hg were considered hypertensive levels; any patient with FBS ≥126mg/dl (or) RBS ≥200mg/dl was defined diabetic. Each case underwent the investigations – Plasma Lipoprotein (a) Levels, Lipid Profile, Complete Hemogram, Complete Urine Examination, Blood Sugars, Renal Function Tests, Serum Electrolytes, ECG, Echocardiography*, X-Ray, CT-Brain*, MRI-Brain*. Lp (a) was measured by a Hitachi model 717 (7160) automated analyser using Lp (a) Latex DIACHI kit. *Denotes whenever required. Results: In the present study, cases of ischemic stroke (n = 100) had a mean plasma Lp (a) value of 38.034 mg/dl with a S.D. of 17.423, which was significantly higher (p = 0.001) than in healthy controls, in whom it was 24.308 mg/dl with a S.D. of 11.469, indicating that serum lipoprotein (a) levels are a risk factor of ischemic stroke. Conclusion: Elevated serum Lp (a) is an independent risk factor of ischemic stroke. Measurement of serum Lp (a) has to be considered as a screening tool for the risk of vascular events in patients with various known risk factors. It is imperative to strictly control additional risk factors in individuals with elevated Lp (a).

Cilostazol for intermittent claudication.

Peripheral arterial disease (PAD) affects between 4% and 12% of people aged 55 to 70 years, and 20% of people over 70 years. A common complaint is intermittent claudication(exercise-induced lower limb pain relieved by rest).Thesepatients have a three- to six-fold increase in cardiovascular mortality. Cilostazol is a drug licensed for the use of improving claudication distance and, if shown to reduce cardiovascular risk,could offer additional clinical benefits. This is an update of the review first published in 2007. To determine the effect of cilostazolon initial and absolute claudication distances, mortality and vascular events in patients with stable intermittent claudication. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries, on 9 November 2020. We considered double-blind, randomised controlled trials (RCTs) of cilostazol versus placebo, or versus other drugs used to improve claudication distance in patients with stable intermittent claudication. Two authors independently assessed trials for selection and independently extracted data. Disagreements were resolved by discussion. We assessed the risk of bias with the Cochrane risk of bias tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we used odds ratios (ORs) with corresponding 95% confidence intervals (CIs) and for continuous outcomes we used mean differences (MDs) and 95% CIs. We pooled data using a fixed-effect model, or a random-effects model when heterogeneity was identified. Primary outcomes were initial claudication distance (ICD) and quality of life (QoL). Secondary outcomes were absolute claudication distance (ACD), revascularisation, amputation, adverse events and cardiovascular events. We included 16 double-blind, RCTs (3972 participants) comparing cilostazol with placebo, of which five studies also compared cilostazol with pentoxifylline. Treatment duration ranged from six to 26 weeks. All participants had intermittent claudication secondary to PAD. Cilostazol dose ranged from 100 mg to 300 mg; pentoxifylline dose ranged from 800 mg to 1200 mg. The certainty of the evidence was downgraded by one level for all studies because publication bias was strongly suspected. Other reasons for downgrading were imprecision, inconsistency and selective reporting. Cilostazol versus placebo Participants taking cilostazol had a higher ICD compared with those taking placebo (MD 26.49 metres; 95% CI 18.93 to 34.05; 1722 participants; six studies; low-certainty evidence). We reported QoL measures descriptively due to insufficient statistical detail within the studies to combine the results; there was a possible indication in improvement of QoL in the cilostazol treatment groups (low-certainty evidence). Participants taking cilostazol had a higher ACD compared with those taking placebo (39.57 metres; 95% CI 21.80 to 57.33; 2360 participants; eight studies; very-low certainty evidence). The most commonly reported adverse events were headache, diarrhoea, abnormal stools, dizziness, pain and palpitations. Participants taking cilostazol had an increased odds of experiencing headache compared to participants taking placebo (OR 2.83; 95% CI 2.26 to 3.55; 2584 participants; eight studies; moderate-certainty evidence).Very few studies reported on other outcomes so conclusionson revascularisation, amputation, or cardiovascular events could not be made. Cilostazol versus pentoxifylline There was no difference detected between cilostazol and pentoxifylline for improving walking distance, both in terms of ICD (MD 20.0 metres, 95% CI -2.57 to 42.57; 417 participants; one study; low-certainty evidence); and ACD (MD 13.4 metres, 95% CI -43.50 to 70.36; 866 participants; two studies; very low-certainty evidence). One study reported on QoL; the study authors reported no difference in QoL between the treatment groups (very low-certainty evidence). No study reported on revascularisation, amputation or cardiovascular events. Cilostazol participants had an increased odds of experiencing headache compared with participants taking pentoxifylline at 24 weeks (OR 2.20, 95% CI 1.16 to 4.17; 982 participants; two studies; low-certainty evidence). Cilostazol has been shown to improve walking distance in people with intermittent claudication. However, participants taking cilostazol had higher odds of experiencing headache. There is insufficient evidence about the effectiveness of cilostazol for serious events such as amputation, revascularisation, and cardiovascular events. Despite the importance of QoL to patients, meta-analysis could not be undertaken because of differences in measures used and reporting. Very limited data indicated no difference between cilostazol and pentoxifylline for improving walking distance and data weretoo limited for any conclusions on other outcomes.

The Anatomy of Recurrent Thrombosis and Its Risk Factors in Myeloproliferative Neoplasms

Background:The main objective of current treatment in both essential thrombocythemia (ET) and polycythemia vera (PV) is to prevent thrombotic complications, specifically in high-risk patients. The most reliable predictor for such complications is a similar previous event. The current study considered the central importance of thrombosis history in predicting future events in ET and PV and, therefore, focused only on patients presenting with a history of thrombosis; the objective was to identify additional risk factors and assess the impact of anti-thrombosis treatment documented at the time of diagnosis.Methods:Study patients were selected from our institutional database of MPN, based on documentation of thrombosis history at or before the time of diagnosis, made according to WHO criteria (Arber et al. Blood 2016;127:2391). Statistical analyses considered clinical and laboratory data collected at the time of diagnosis. Thrombosis-free survival (TFS) was calculated both by considering all vascular events (arterial + venous) as well as by separately analyzing arterial vs venous TFS.Results:i) Presenting features:A total of 290 patients with ET (n=175) or PV (n=115) presented with history of thrombosis, either “at” (n=146; 50%) or “before” (n=194; 67%) the time of diagnosis. The respective arterial vs venous distribution of events was 35% vs 15% “at” and 49% vs 21% “before” the time of diagnosis. When ET and PV were analyzed separately, the respective incidences of thrombosis history (arterial + venous) were 19% vs. 25% (p=0.02) “at” and 64% vs 71% (p=0.19) “before” the time of diagnosis; the respective figures for arterial thrombosis were 44% vs 21% (p=0.0002) “at” and 50% vs 44% (p=0.75) “before” time of diagnosis and for venous thrombosis 12% vs 18% (p=0.13) “at” and 18% vs 23% (p=0.12) “before” time of diagnosis.ii) Treatment documented at time of diagnosis:Treatment at time of diagnosis was documented in 95% of the patients and included cytoreductive therapy in 82%, anti-platelet therapy in 61% and systemic anticoagulation in 26%, with no significant difference between ET and PV; the most frequent combination therapies were cytoreductive + anti-platelet therapy (42%), cytoreductive therapy alone (19%) and cytoreductive + systemic anticoagulation (13%); 9% of the patients received combination of all three treatment modalities.iii) Post-diagnosis events:Median follow-up was 9 years and was longer for ET (10 years) compared to PV (7 years; p=0.002); during this period, 146 (50%) deaths, 10 (3%) leukemic transformations, 17 (6%) fibrotic progressions, and 86 (30%) thrombotic events were recorded. Among the latter, 72 (25%) were arterial and 22 (8%) were venous. The incidence of post-diagnosis arterial (p=0.2) or venous (p=0.9) events was not significantly different between ET and PV.iv) Risk factors for thrombosis-free survival (including both arterial and venous):In univariate analysis, significant risk factors for arterial + venous TFS included male sex (HR 1.9; 95% CI 1.3-3.0), diabetes history (HR 1.8, 95% CI 1.01-3.2) and use of coumarins (HR 1.7, 95% CI 1.1-2.7). During multivariable analysis, male sex and use of coumarins remained significant.v) Risk factors for arterial vs venous thrombosis-free survival:In univariate analysis, significant risk factors for arterial TFS included older age, male sex and history of arterial thrombosis; male sex (HR 1.7, 95% CI 1.1-2.7) and arterial thrombosis history (HR 2.6, 95% CI 1.3-5.3) remained significant during multivariable analysis. Significant risk factors for venous TFS included history of venous thrombosis (HR 4.9, 95% CI 1.9-12.3) and use of coumarins (HR 5.3, 95% CI 2.2-12.9); both remained significant during multivariable analysis.Conclusions:The significant association between thrombosis history and future vascular events in patients with ET or PV is major vessel-specific in its distribution (i.e. arterial vs venous) and the current study identifies male sex and use of coumarins as additional independent risk factors for arterial and venous events, respectively. The unexpected association between coumarin use and recurrent venous thrombosis might be related to a higher underlying risk in the patients chosen to receive such therapy or detrimental drug effect; prospective studies are needed for further clarification. DisclosuresNo relevant conflicts of interest to declare.

Colchicine for prevention of vascular inflammation in Non-CardioEmbolic stroke (CONVINCE) - study protocol for a randomised controlled trial.

Inflammation contributes to unstable atherosclerotic plaque and stroke. In randomised trials in patients with coronary disease, canukinumab (an interleukin-1B antagonist) and colchicine (a tubulin inhibitor with pleiotropic anti-inflammatory effects) reduced recurrent vascular events.Hypothesis: Anti-inflammatory therapy with low-dose colchicine plus usual care will reduce recurrent vascular events in patients with non-severe, non-cardioembolic stroke and TIA compared with usual care alone. CONVINCE is a multi-centre international (in 17 countries) Prospective, Randomised Open-label, Blinded-Endpoint assessment (PROBE) controlled Phase 3 clinical trial in 3154 participants. The intervention is colchicine 0.5 mg/day and usual care versus usual care alone (antiplatelet, lipid-lowering, antihypertensive treatment, lifestyle advice). Included patients are at least 40 years, with non-severe ischaemic stroke (modified Rankin score ≤3) or high-risk TIA (ABCD2 > 3, or positive DWI, or cranio-cervical artery stenosis) within 72 hours-28 days of randomisation, with qualifying stroke/TIA most likely caused by large artery stenosis, lacunar disease, or cryptogenic embolism. Exclusions are stroke/TIA caused by cardio-embolism or other defined cause (e.g. dissection), contra-indication to colchicine (including potential drug interactions), or incapacity for participation in a clinical trial. The anticipated median follow-up will be 36 months. The primary analysis will be by intention-to-treat. The primary outcome is time to first recurrent ischaemic stroke, myocardial infarction, cardiac arrest, or hospitalisation with unstable angina (non-fatal or fatal). CONVINCE will provide high-quality randomised data on the efficacy and safety of anti-inflammatory therapy with colchicine for secondary prevention after stroke. First-patient first-visit was December 2016. Recruitment to complete in 2021, follow-up to complete in 2023.

Total Ischemic Event Reduction With Rivaroxaban After Peripheral Arterial Revascularization in the VOYAGER PAD Trial

BackgroundPatients with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER) are at high risk of major adverse limb and cardiovascular events. The VOYAGER PAD (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities) trial demonstrated that rivaroxaban 2.5 mg twice daily reduced first events by 15%. The benefit of rivaroxaban on total (first and subsequent) events in this population is unknown. ObjectivesThis study sought to evaluate the total burden of vascular events in patients with PAD after LER and the efficacy of low-dose rivaroxaban on total events. MethodsVOYAGER PAD randomized patients with PAD undergoing LER to rivaroxaban 2.5 mg twice daily plus aspirin or aspirin alone. The primary endpoint was time to first event of acute limb ischemia, major amputation of a vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. The current analysis considered all events (first and subsequent) for components of the primary endpoint as well as additional vascular events including peripheral revascularizations and venous thromboembolism. HRs were estimated by marginal proportional hazards models. ResultsAmong 6,564 randomized events, there were 4,714 total first and subsequent vascular events including 1,614 primary endpoint events and 3,100 other vascular events. Rivaroxaban reduced total primary endpoint events (HR: 0.86; 95% CI: 0.75-0.98; P = 0.02) and total vascular events (HR: 0.86; 95% CI: 0.79-0.95; P = 0.003). An estimated 4.4 primary and 12.5 vascular events per 100 participants were avoided with rivaroxaban over 3 years. ConclusionsPatients with symptomatic PAD who are undergoing LER have a high total event burden that is significantly reduced with rivaroxaban. Total event reduction may be a useful metric to quantify the efficacy of rivaroxaban in this setting. (Efficacy and Safety of Rivaroxaban in Reducing the Risk of Major Thrombotic Vascular Events in Subjects With Symptomatic Peripheral Artery Disease Undergoing Peripheral Revascularization Procedures of the Lower Extremities [VOYAGER PAD]; NCT02504216)

Impact of Lower Versus Higher LDL Cholesterol Targets on Cardiovascular Events After Ischemic Stroke in Patients With Diabetes.

After an ischemic stroke with evidence of atherosclerosis, lipid-lowering treatment with a target LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL reduced the risk of subsequent cardiovascular events. In this analysis, we explored the effect in the subgroup of patients with diabetes compared with the subgroup without, as well as in those with newly diagnosed diabetes. Patients with ischemic stroke in the previous 3 months or transient ischemic attack within the previous 15 days and evidence of cerebrovascular or coronary artery atherosclerosis were randomly assigned at a 1:1 ratio to a target LDL cholesterol of <70 mg/dL or 100 ± 10 mg/dL using statin or ezetimibe. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization, and death resulting from vascular disease. We performed a prespecified analysis to evaluate the effect in patients with diabetes. Of 2,860 patients enrolled, 643 had diabetes at baseline, with a mean age of 66.2 years and baseline LDL cholesterol of 127 mg/dL, and were followed for a median of 3 years. The primary composite end point occurred in 27 (8.2%) of 328 patients in the lower-target group and in 44 (14.0%) of 315 patients in the higher-target group (adjusted hazard ratio [HR] 0.56; 95% CI 0.34-0.89; P = 0.016). In patients without diabetes, the HR was 0.87 (95% CI 0.66-1.14; P = 0.31; interaction P = 0.15). In those with diabetes, there were three intracranial hemorrhages in both randomization groups (0.9% vs. 1.0%, respectively). Newly diagnosed diabetes occurred in 98 (9.2%) of 1,070 and in 80 (7.4%) of 1,085 patients in the lower- and higher-target groups, respectively (HR 1.27; 95% CI 0.94-1.71; P = 0.11), and baseline higher HbA1c was the unique multivariable predictor. In conclusion, after an ischemic stroke with evidence of atherosclerosis, targeting an LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL consistently reduced the risk of subsequent stroke and other major vascular events in patients with and without diabetes, but the higher risk in those with diabetes yielded a higher absolute risk reduction, with number needed to treat of 17.

Carotid intraplaque neovascularisation as a predictive factor for future vascular events in patients with mild and moderate carotid stenosis: an observational prospective study.

Background:Intraplaque neovascularisation (IPN) increases the vulnerability of plaques, which makes them more likely to rupture and increases the risk of vascular events. However, it is unclear whether IPN can predict future vascular events (stroke recurrence and cardiovascular events). Previous studies on IPN have focused on patients with severe stenosis but overlooked patients with mild and moderate stenosis. This study aimed to investigate whether IPN assessed by contrast-enhanced ultrasonography (CEUS) in patients with mild and moderate degrees of stenosis is associated with future vascular events.Methods:One hundred and twenty-one patients participated in this study. 76 patients who met the inclusion and exclusion criteria were included in the final dataset of the study. IPN was graded from 0 to 2 according to the extent of the microbubbles assessed using CEUS. The degree of carotid stenosis was graded as mild, moderate, or severe. We recorded future vascular events during the follow-up. Univariate and multivariate logistic regression analyses were used to evaluate risk factors for future vascular events.Results:After a follow-up period of 30 ± 6 months, 30 patients (39.5%) experienced subsequent vascular events. Compared with the ‘non-recurrent’ group, the ‘recurrent’ group showed a higher proportion of grade 2 neovascularisation (p < 0.05), and it was an independent predictor of subsequent vascular events (odds ratio 6.066, 95% confidence interval 1.565–23.512, p < 0.05). Furthermore, in patients with mild and moderate stenosis, future vascular events occurred in an unexpectedly high proportion (up to 42.9%). In the ‘recurrent’ group, 55% of patients with mild and moderate stenosis had grade 2 neovascularisation.Conclusion:IPN by CEUS was an independent predictor of future vascular events in patients with recent ischemic stroke, and the high proportion of neovascularisation in patients with mild and moderate stenosis requires more attention.

Risk factors for symptomatic vascular events in giant cell arteritis: a study of 254 patients with large-vessel imaging at diagnosis.

Aims:To identify factors associated with vascular events in patients with giant cell arteritis (GCA).Methods:We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis. Symptomatic vascular events were defined as the occurrence of any aortic event (aortic dissection or symptomatic aortic aneurysm), stroke, myocardial infarction, limb or mesenteric ischemia and de novo lower limbs arteritis stage 3 or 4. Patients with symptomatic vascular event (VE+) and without were compared, and risk factors were identified in a multivariable analysis.Results:Thirty-nine (15.4%) of the 254 included patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months. Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were more frequent in VE+ patients (p < 0.05), as an abnormal computed tomography (CT)-scan at diagnosis (p = 0.04), aortitis (p = 0.01), particularly of the descending thoracic aorta (p = 0.03) and atheroma (p = 0.03). Deaths were more frequent in the VE+ group (37.1 versus 10.3%, p = 0.0003). In multivariable analysis, aortic surgery [hazard ratio (HR): 10.46 (1.41–77.80), p = 0.02], stroke [HR: 22.32 (3.69–135.05), p < 0.001], upper limb ischemia [HR: 20.27 (2.05–200.12), p = 0.01], lower limb ischemia [HR: 76.57 (2.89–2027.69), p = 0.009], aortic atheroma [HR: 3.06 (1.06–8.82), p = 0.04] and aortitis of the descending thoracic aorta on CT-scan at diagnosis [HR: 4.64 (1.56–13.75), p = 0.006] were independent predictive factors of a vascular event.Conclusion:In this study on GCA cases with large vessels imaging at diagnosis, aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event.Plain language summaryRisk factors for symptomatic vascular events in giant cell arteritisThis study was performed to identify the risk factors for developing symptomatic vascular event during giant cell arteritis (GCA) because these are poorly known.We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis.Patients with symptomatic vascular event (VE+) and without (VE-) were compared, and risk factors were identified in a multivariable analysis.Thirty-nine patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months.Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were significantly more frequent in VE+ patients, as an abnormal CT-scan at diagnosis, aortitis, particularly of the descending thoracic aorta and atheroma. Deaths were more frequent in the VE+ group.Among 254 GCA patients, 39 experienced at least one vascular event during follow-up.Aortic surgery, stroke, upper and lower limb ischemia were vascular event risk factors.Aortic atheroma and descending thoracic aorta aortitis on CT-scan were vascular event risk factors.This study on GCA cases with large vessels imaging at diagnosis, showed that aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event.

Ischemic Bowel Mimicking a Colonic Mass in RS3PE Syndrome

Remitting seronegative symmetrical synovitis with pitting edema syndrome is characterized by symmetrical synovitis involving wrists and flexor digitorum tendon sheaths associated with marked pitting edema of the dorsum of hands. It is considered a paraneoplastic syndrome. Here we describe a middle-aged patient with this syndrome presenting with acute abdomen and ischemic bowel mimicking a colonic mass. Rheumatologists and surgeons should consider mesenteric vascular events in patients with remitting seronegative symmetrical synovitis with pitting edema who present with acute abdomen, even in patients younger than 50 years. Our case is the first case in the literature reporting the association between ischemic infarction of colon and remitting seronegative symmetrical synovitis with pitting edema. Remitting seronegative symmetrical synovitis with pitting edema needs to be listed among other rheumatologic diseases associated with mesenteric vascular occlusion.

Ефективність противірусної терапії у вторинній профілактиці ішемічного інсульту на тлі маніфестації вірусної інфекції

Recurrent stroke remains the key health issue in the world. A higher three-year recurrence rate of stroke in patients with persistence of the genome of herpes viruses, and with presence in the blood of the genome of at least 2 types of viruses was identified. These investigations demonstrate the importance of further research into the role of antiviral therapy in improving the rehabilitation and secondary prevention of stroke in patients with persistent viral infection The purpose of the study was to evaluate the effectiveness of antiviral therapy in the secondary ischemic stroke prevention on the viral infection manifestation background. Material and methods. The study included 105 patients with moderate to severe ischemic stroke with a viral manifestation confirmed by the detection of herpes virus’s DNA (HSV1, HSV2, EBV, CMV, HHV6) and Flu RNA. Patients who were additionally prescribed antiviral drugs on the background of traditional therapy were in the main group (n = 35). Patients who received only traditional, recommended by the modern stroke treatment guidelines, therapy and secondary stroke prevention measures were included in the comparison group (n = 70). Results and discussion. We found that the effectiveness of the proposed preventive treatment depended on the viral load of the patient. In the presence of three or more types of viruses, the proposed therapy provided a significantly lower ischemic stroke recurrence rate, compared to the patients who did not receive antiviral therapy 11.1% vs. 49.8%, p = 0.042. Prevention of recurrent ischemic stroke, which should have started as soon as possible after the development of the first stroke or transient ischemic attack occurrence, F. Rincon and R. L. Sacco (2008) consider the most relevant in this group of patients. Herewith, as emphasized by D. G. Hackam and J. D. Spence (2007), comprehensive prevention has reduced the risk of recurrent ischemic stroke by almost 80%, thus preventing 4 out of 5 possible disorders. However, both native and world literature still has a lack of systematic data of the problem of antiviral therapy using in patients with acute disorders of cerebral circulation, although it has been proven that infectious and inflammatory complications are an important pathogenetic factor of its unfavorable and severe outcome. M. S. Elkind et al. (2016) consider that antiviral drugs such as acyclovir may play an appropriate role in the prevention of recurrent ischemic stroke in children if their causal relation is confirmed. Conclusion. The use of acyclovir in complex rehabilitation therapy and secondary stroke prevention in patients with viral infection manifestation provided an increase in the average score of Bartel index after 1 year, p = 0.017. In the case of antiviral therapy using in the complex prevention of recurrent vascular events in patients with viral infection manifestation, the three-year recurrence rate of stroke is lower (p = 0.042)

Rates of Vascular Events in Patients With Migraine: A MarketScan® Database Retrospective Cohort Study.

ObjectiveTo estimate the baseline rates of vascular events among people with migraine.BackgroundSeveral novel medications that target the calcitonin gene‐related peptide (CGRP) pathway are approved to treat people with migraine. Given that the CGRP pathway also plays a role in maintaining cardiovascular homeostasis, determining the baseline rates of vascular events among people with migraine will help inform the safety of these novel medications.MethodsIn this retrospective cohort study, patients 18‐ to 64‐year‐old patients with migraine were identified from the MarketScan® database (January 2013‐December 2017) and were categorized into 4 vascular risk categories: migraine with aura; and high, medium, and low vascular risk. Event rates (per 1000 person‐years [PY]) for 19 vascular events were estimated overall, by risk category, and by baseline characteristics.ResultsAmong 1,195,696 patients with migraine, 4.8% (57,853/1,195,696) had migraine with aura, and 2.8% (33,949/1,195,696), 15.5% (184,782/1,195,696), and 77.9% (931,059/1,195,696) were at high, medium, and low risk of vascular events, respectively. Rates of ischemic stroke (per 1000 PY) were 5.1 (95% confidence interval [CI]: 5.0, 5.2) overall, 8.6 (95% CI: 8.1, 9.1) for patients with migraine aura, 47.2 (95% CI: 45.3, 49.0) in the high‐risk group, 9.4 (95% CI: 9.1, 9.7) in the medium‐risk group, and 2.9 (95% CI: 2.9, 3.0) in the low‐risk group. Rates of acute myocardial infarction (per 1000 PY) were 1.8 (95% CI: 1.8, 1.9) overall, 1.9 (95% CI: 1.7, 2.2) for patients with migraine aura, 14.0 (95% CI: 13.0, 14.9) in the high‐risk group, 3.9 (95% CI: 3.7, 4.1) in the medium‐risk group, and 1.1 (95% CI: 1.0, 1.1) in the low‐risk group. High‐risk patients had the highest rates of each of 19 evaluated vascular events, and rates were higher for men, older age groups, and those with higher comorbidity scores, medication usage, and medical utilization.ConclusionOur findings provide recent rates of vascular disease in patients with migraine. In the future, this information will be useful to help inform clinical risk:benefit decision making when assessing the use of therapies such as CGRP antagonists for migraine.

Targeting Inflammation to Reduce Residual Cardiovascular Risk.

Patients with established cardiovascular disease are at high risk for recurrent myocardial infarction, stroke, and cardiovascular death. The term residual risk refers to this risk that persists, even after optimal treatment. Considerable progress has been made to understand the biological basis of residual risk and to devise therapies that can safely and effectively reduce risk. The presence of ongoing subclinical vascular inflammation is known to be a marker of elevated residual risk, and reductions in measures of vascular inflammation predict improved outcome in these patients. Recent trials of anti-inflammatory agents have specifically tested the hypothesis that inflammation reduction reduces residual cardiovascular risk. Most prominent among these are the CANTOS, COLCOT, and CIRT trials. CANTOS enrolled patients with prior myocardial infarction (MI) and a high-sensitivity C-reactive protein ≥ 2 mg/L and reported a 15% reduction in major adverse cardiovascular events (MACE; HR 0.85, 95% CI 0.74-0.98) with the interleukin-1β inhibitor canakinumab. In COLCOT, colchicine 0.5mg daily led to a 23% relative risk reduction (HR 0.77, 95% CI 0.61-0.96) in major vascular events in patients with recent acute coronary syndrome. By contrast, CIRT was stopped early for lack of benefit of low-dose methotrexate in preventing MACE in patients with coronary artery disease and either type 2 diabetes or the metabolic syndrome. Ongoing subclinical inflammation is an important marker of risk in patients with established cardiovascular disease, and novel therapies targeted at specific inflammatory pathways now demonstrate efficacy for the prevention of major adverse cardiovascular events.

MPN-316: Impact of Comorbidities in Philadelphia Chromosome-Negative Myeloproliferative Neoplasms

Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) are hematological disorders that occur due to clonal proliferation. Thrombosis and bleeding are more common in MPN patients in comparison to normal population. Comorbidity is a well-known negative prognostic factor for survival of patients with cancer. The aim of this study is to show the impact of comorbidities using the Charlson Comorbidity Index (CCI) on thrombotic events and bleeding episodes, as well as survival outcome in Philadelphia-negative MPNs. A retrospective cross-sectional study was carried out at Upper Egypt in Qena University hospital and Assiut University hospital between January 2014 and December 2018, in which clinical, molecular, and laboratory data of MPN patients were included. This cohort included: 62 primary myelofibrosis (PMF; 32.7%), 89 polycythemia vera (PV; 46.8%) and 39 essential thrombocytosis (ET; 20.5%) patients. Diagnosis was based on the WHO classification 2008. We computed the CCI on 190 MPN patients at diagnosis; CCI is a list of 19 comorbid conditions: each condition has a weight assigned from 1 to 6 to study the effect of comorbidity on risks of vascular events in patients with MPN, as well as survival. The endpoints were a venous or arterial thrombotic event and bleeding episodes. One-quarter of patients (n=50; 26.3%) had CCI zero (low comorbidity), 83 (43.7%) had a CCI 1–2 (moderate), and 57 (30%) had a CCI > 2 (severe). The most common comorbidities were hypertension (32.1%), coronary artery disease (12.1%), diabetes (12%), and others as reported accordingly. Forty-two patients (22.1%) had a thrombotic episode (29/42) at the time of diagnosis. CCI was significantly higher in patients with a thrombotic event vs. patients without a thrombotic event (P ≤ 0.001). CCI was higher (although not significantly) in patients with bleeding episodes of any grade vs. patients without a bleeding event (P=0.42). Overall survival (P ≤ 0.001) and progression-free survival (P

Premenapozal migren hastalarında aort sertliği parametrelerinin değerlendirilmesi

Purpose: Migraine is an episodic primary headache disorder, which affects approximately 10% of the adult population, predominantly females. Based on the changes detected in migraine and previous findings, arterial stiffness can be considered to be an important contributor to vascular events in patients with migraine. The aim of this study was to investigate the associations between atherosclerosis and migraine through the evaluation of aortic stiffness in premenopausal migraine patients.Materials and Methods: The study included 68 female patients with migraine, and a control group of 39 healthy females. To reveal the association between migraine and arterial stiffness, echocardiography was applied and aortic stiffness was evaluated. Blood pressure measurements, basic biochemical tests and the 12 derivation-ECG recordings of each patient were taken simultaneously. Results: Basic echocardiographic findings were similar in patients and the control group. Systolic and diastolic diameters of the aorta, and the change in aortic diameter were also similar in both groups. Aortic distensibility, aortic strain and beta indices were also similar in both groups. No significant differences were determined between patients with and without aura migraine and the control group in respect of systolic blood pressure, diastolic blood pressure and pulse pressure. Conclusion: As a marker of atherosclerosis, the aortic stiffness parameters didn’t differ between migraine and control group.

Different contribution of SBP and DBP variability to vascular events in patients with stroke

BackgroundHigh blood pressure variability (BPV) is a novel risk factor for cardiovascular disease. However, the heterogeneity of systolic blood pressure variability (SBPV) and diastolic blood pressure variability (DBPV) for different...

Acute coronary syndromes and acute heart failure: a diagnostic dilemma and high-risk combination. A statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology.

Acute coronary syndrome is a precipitant of acute heart failure in a substantial proportion of cases, and the presence of both conditions is associated with a higher risk of short-term mortality compared to acute coronary syndrome alone. The diagnosis of acute coronary syndrome in the setting of acute heart failure can be challenging. Patients may present with atypical or absent chest pain, electrocardiograms can be confounded by pre-existing abnormalities, and cardiac biomarkers are frequently elevated in patients with chronic or acute heart failure, independently of acute coronary syndrome. It is important to distinguish transient or limited myocardial injury from primary myocardial infarction due to vascular events in patients presenting with acute heart failure. This paper outlines various clinical scenarios to help differentiate between these conditions and aims to provide clinicians with tools to aid in the recognition of acute coronary syndrome as a cause of acute heart failure. Interpretation of electrocardiogram and biomarker findings, and imaging techniques that may be helpful in the diagnostic work-up are described. Guidelines recommend an immediate invasive strategy for patients with acute heart failure and acute coronary syndrome, regardless of electrocardiographic or biomarker findings. Pharmacological management of patients with acute coronary syndrome and acute heart failure should follow guidelines for each of these syndromes, with priority given to time-sensitive therapies for both. Studies conducted specifically in patients with the combination of acute coronary syndrome and acute heart failure are needed to better define the management of these patients.

Colchicine for stroke prevention in patients with coronary artery disease: a systematic review and meta-analysis.

Although clinical trials suggest that colchicine may reduce the risk of vascular events in patients with a history of coronary artery disease, its effect on the prevention of cerebrovascular events still remains unclear. A systematic review and meta-analysis was performed of all available randomized controlled trials (RCTs) reporting on incident strokes during the follow-up of patients with a history of cardiovascular disease randomized to colchicine treatment or control (placebo or usual care). Four RCTs were identified, including a total of 5553 patients (mean age 61years, 81% males), with a follow-up ranging from 1 to 36months. Colchicine treatment was associated with a significantly lower risk of incident stroke during follow-up compared to control (risk ratio0.31, 95% confidence interval 0.13-0.71), without heterogeneity across included studies (I2 =0%). Based on the pooled incident stroke rate of control groups (0.9%) in the included RCTs, it was estimated that administration of low-dose colchicine to 161 patients with coronary artery disease would prevent one stroke during a follow-up of 23months. Colchicine treatment decreases stroke risk in patients with a history of coronary artery disease. The effect of colchicine in secondary stroke prevention is currently being evaluated in an ongoing RCT.

Aspirin Resistance Affects Medium-Term Recurrent Vascular Events after Cerebrovascular Incidents: A Three-Year Follow-up Study

Background: The aim of this prospective, a three-year follow-up study, was to establish the role of high on-treatment platelet reactivity (HTPR) in predicting the recurrence of vascular events in patients after cerebrovascular incidents, particularly in the aspect of stroke etiology. Methods: The study included 101 subjects with non-embolic cerebral ischemia (69 patients with ischemic stroke and 32 patients with transient ischemic attack) treated with 150 mg of acetylsalicylic acid (aspirin) a day. The platelet reactivity was tested in the first 24 h after the onset of cerebral ischemia by impedance aggregometry. Recurrent vascular events, including recurrent ischemic stroke, transient ischemic attack, myocardial infarction, systemic embolism, or sudden death of vascular reason, were assessed 36 months after the onset of cerebral ischemia. Results: Recurrent vascular events occurred between 3 and 9 months after onset in 8.5% of all subjects; in the HTPR subgroup, recurrent vascular events occurred in 17.9%; in the normal on-treatment platelet reactivity (NTPR) subgroup, they occurred in 4.6%. We did not notice early or long-term recurrent events. Aspirin resistant subjects had a significantly higher risk of recurrent vascular events than did aspirin sensitive subjects (Odds ratio (OR) = 4.57, 95% Confidence interval (CI) 1.00–20.64; p = 0.0486). Cox proportional hazard models showed that large-vessel disease (Hazard ratio (HR) 12.04, 95% CI 2.43–59.72; p = 0.0023) and high on-treatment platelet reactivity (HR 4.28, 95% CI 1.02–17.93; p = 0.0465) were independent predictors of recurrent vascular events. Conclusion: Aspirin resistance in the acute phase of cerebral ischemia was associated with a higher risk of recurrent medium-term vascular events, coexisting with large-vessel etiology of stroke. Platelet function-guided personalized antiplatelet treatment should be considered for patients with recurrent strokes, especially when due to large-vessel disease.

Influence of Hemoglobin Concentration on Stroke Recurrence and Composite Vascular Events.

Background and Purpose- We evaluated whether hemoglobin concentration at admission was associated with stroke recurrence and composite vascular events (stroke, myocardial infarction, and vascular death) in acute ischemic stroke. Methods- We collected data from patients with acute ischemic stroke or transient ischemic attack from a multicenter stroke registry database in Korea. The association of hemoglobin concentration with 1-year stroke recurrence and composite vascular events was evaluated with respect to age, presence of cerebral artery stenosis, stroke severity, and stroke subtype. Results- Hemoglobin levels were inversely associated with stroke recurrence and composite vascular events. One-year rates of stroke recurrence and composite vascular events were significantly higher in patients with anemia or moderate anemia. In multivariable analyses, moderate anemia remained an independent predictor of stroke recurrence (adjusted hazard ratio, 1.43 [95% CI, 1.16-1.75]) and composite vascular events (adjusted hazard ratio, 1.26 [95% CI, 1.07-1.48]). Moderate anemia increased the risk of composite vascular events in patients with mild-to-moderate stroke severity (National Institutes of Health Stroke Scale score <16, P=0.01 for interaction). Conclusions- Hemoglobin concentration could be an independent predictor of stroke recurrence and composite vascular events.

Abstract TMP54: A VA Observational Study Examining the Benefit of Various Post-Ischemic Stroke/Tia Hypertension Goals in Preventing Recurrent Vascular Events

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of &lt; 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of &lt; 130/80 mmHg for patients with ischemic stroke/TIA. Understanding the potential benefit in preventing recurrent vascular events for patients reaching ACC/AHA BP goals is necessary to inform clinical care. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up. Vascular events were defined as cerebrovascular-only, cardiovascular-only, and the composite of each. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and &gt;140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to recurrent event 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year recurrent vascular event rates. Results: A total of 12,337 eligible patients were included in the final analysis. Compared to those with SBP &gt; 140 mmHg, patients reaching ACC/AHA BP goal had significant lower risk of cerebrovascular recurrent events (HR=0.77, 95% CI=0.60-0.99) but not cardiovascular recurrence or both combined. Conclusions: In considering BP reached by 90-days, ACC/AHA BP guidelines showed protective effects on cerebrovascular event recurrence only.