Year Risk Of Stroke Research Articles

Abstract 15803: Effectiveness of Direct Oral Anticoagulant versus Warfarin in the Treatment of Left Ventricular Thrombus

Introduction: Left ventricular thrombus (LVT) is associated with a higher risk of ischemic stroke and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. Data on natural history and thrombus resolution with anticoagulation (AC), especially with DOACs is scarce. We studied the natural history of LVT with AC with emphasis on comparing warfarin and DOACs use. Methods: This is a single center, retrospective study conducted in an academic medical center. We identified patients (echocardiogram, CT or MRI) with a confirmed LVT study who were followed at our center. Chart review was conducted to collect clinical information at presentation and on follow up. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, mortality) were recorded. Thrombus resolution on follow up imaging was also recorded. Results: LVT was confirmed in a total of 110 patients. Mean age was 59±14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients (in remaining patients AC was thought to be contraindicated). Of those on long-term AC, 60 patients (63%) were treated with warfarin, 3 patients (3%) with enoxaparin and 32 patients (33%) with a DOACs. At one year follow up, 11 patients (10%) had a stroke while on any AC. Two of these patients had hemorrhagic stroke (both on warfarin) and 9 patients had ischemic stroke. Of those with ischemic stroke 7 were on warfarin and 2 patients on DOACs had ischemic strokes. Of those with ischemic stroke on warfarin, 71% had subtherapeutic INR. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p= 0.33). Total of 55 (57%) of patient started on AC had resolution of thrombus. 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p= 0.85). Conclusions: One year risk of stroke with LVT is high (10%) even with AC. Most patients with ischemic stroke on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients.

Cerebral Small Vessel Disease in Standard Pre-operative Imaging Reports Is Independently Associated with Increased Risk of Cardiovascular Death Following Carotid Endarterectomy

Cerebral white matter lesions (WMLs) and lacunar infarcts are surrogates of cerebral small vessel disease (SVD). WML severity as determined by trained radiologists predicts post-operative stroke or death in patients undergoing carotid endarterectomy (CEA). It is unknown whether routine pre-operative brain imaging reports as part of standard clinical practice also predict short and long term risk of stroke and death after CEA. Consecutive patients from the Athero-Express biobank study that underwent CEA for symptomatic high degree stenosis between March 2002 and November 2014 were included. Pre-operative brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) reports were reviewed for reporting of SVD, defined as WMLs or any lacunar infarcts. The primary outcome was defined as any stroke or any cardiovascular death over three year follow up. The secondary outcome was defined as the 30 day peri-operative risk of stroke or cardiovascular death. A total of 1038 patients were included (34% women), of whom 659 (63.5%) had CT images and 379 (36.5%) MRI images available. Of all patients, 697 (67%) had SVD reported by radiologists. Patients with SVD had a higher three year risk of cardiovascular death than those without (6.5% vs. 2.1%, adjusted HR 2.52 [95% CI 1.12-5.67]; p=.026) but no association was observed for the three year risk of stroke (9.0% vs. 6.7%, for patients with SVD vs. those without, adjusted HR 1.24 [95% CI 0.76-2.02]; p=.395). No differences in 30 day peri-operative risk were observed for stroke (4.4% vs. 2.9%, for patients with vs. those without SVD; adjusted HR 1.49 [95% CI 0.73-3.05]; p=.28), and for the combined stroke/cardiovascular death risk (4.4% vs. 3.5%, adjusted HR 1.20 [95% CI 0.61-2.35]; p=.59). Presence of SVD in pre-operative brain imaging reports can serve as a predictor for the three year risk of cardiovascular death in symptomatic patients undergoing CEA but does not predict peri-operative or long term risk of stroke.

Sickle cell disease: primary stroke prevention.

Stroke is an important and common complication of sickle cell disease (SCD), affecting children as well as adults. Clinically evident stroke, usually brain infarction, is usually associated with stenosis or occlusion of the intracranial arteries of the Circle of Willis, sometimes with formation of moyamoya (a Japanese word for "hazy" or "like a puff of smoke" that describes the appearance of a abnormal microvasculature on angiography believed secondary to internal carotid artery stenosis or occlusion and the resultant extensive collateralization). Several types of intracranial hemorrhage are observed but usually in older children and adults. Cerebrovascular diseases restricted to small vessels may go unrecognized but is associated with cognitive and learning problems. Prevention of recurrent stroke has been accomplished with chronic blood transfusion. A primary prevention strategy for clinical stroke, based on the Stroke Prevention in Sickle Cell Anemia Trial, has been tested in a randomized clinical trial. Over 2,000 young children with SCD were screened with transcranial Doppler ultrasound (TCD) to detect elevated blood flow velocity indicative of vessel disease and high risk of future stroke. Those randomized to standard care (no transfusion) had a 10%/year risk of stroke, which was reduced >90% with chronic transfusion. This approach is the only primary stroke prevention strategy so far tested in SCD in a randomized controlled trial. Silent lesions on magnetic resonance imaging are associated with an approximately 1.5%/year risk of clinical stroke and a trial is now starting in children with these lesions who do not meet Stroke Prevention in Sickle Cell Anemia Trial criteria for transfusion based on TCD. A controlled trial, based on intervention for nocturnal hypoxemia, is also underway. Hydroxyurea, bone marrow transplantation, antiplatelet, and antithrombotic agents may work but have not been tested in primary prevention in a systematic way. If early and repeated, TCD screening of children, as recommended by National Heart Lung and Blood Institute and the American Stroke Association, were implemented broadly the incidence of new strokes could be greatly reduced in these children.

Tool Judged Best to Predict Stroke After Atrial Fibrillation

A new scheme for assessing stroke risk, based on data amassed in the Anticoagulation and Risk Factors in AF, or ATRIA, cohort, performed better than the schemes currently recommended in leading clinical guidelines, according to a report published online in the Journal of the American Heart Association. In two studies, the ATRIA scores identified a substantially larger proportion of atrial fibrillation patients – 46% – as being at low risk for stroke, compared with other risk schemes currently in widespread use. This would allow clinicians to consider foregoing anticoagulant therapy in nearly half of AF patients. The new scheme was particularly useful in calculating stroke risk in primary prevention patients, “the large group whose stroke risk is the most uncertain and where personalizing the anticoagulation decision is most pressing,” said Dr. Daniel E. Singer of Massachusetts General Hospital, Boston, and his associates. In addition, the ATRIA scores were especially good at predicting severe strokes, the investigators noted. Dr. Singer and his colleagues first used large health-plan databases to identify 13,559 California adults diagnosed as having nonvalvular AF in 1996-1997 and followed through 2003. These study subjects accounted for 33,497 person-years of observation on warfarin and 10,927 person-years of observation off warfarin. There were 685 thromboembolic events, including 643 ischemic strokes, in this derivation cohort. Patient age and personal history of prior stroke were the two factors found to exert the greatest effect on future stroke risk. From these data, the investigators identified eight highly predictive variables to incorporate into their risk assessment model: age, prior stroke, female sex, diabetes, heart failure, hypertension, proteinuria, and end-stage renal disease or an estimated glomerular filtration rate less than 45 mL/min per 1.73 m. This risk-prediction scheme differs from existing schemes primarily in that it uses a broader range of age categories; makes age, prior stroke, and their interaction the predominant risk factors to weigh into the calculation; and adds new high-risk factors such as female sex and renal dysfunction into the calculation. The ATRIA stroke risk score improved on the CHADS2 stroke risk score by 26%, primarily by correctly upgrading many patients from moderate-risk to high-risk categories. And it improved on the CHADS2DS2-VASc stroke risk score by 27%, exclusively by correctly downgrading many patients from high- or moderate-risk categories to the low-risk category. The researchers then confirmed the accuracy of the ATRIA stroke risk scheme by testing it in a validation cohort of 33,247 adults who were newly diagnosed as having AF in 2006-2009. These study subjects accounted for 26,263 person-years off warfarin and 25,306 person-years on warfarin. There were 496 thromboembolic events, including 466 ischemic strokes, in this validation cohort. When the ATRIA scheme was used, the distribution of patients into low-, moderate-, and high-risk categories was “remarkably similar” to that in the derivation cohort. Similarly, the ATRIA scores were much more accurate than those in current standard use at determining which patients were at low risk and which were at high risk for stroke. In particular, 46% of patients in both the derivation and validation cohorts were categorized by their ATRIA score as having a less than 1% per year risk of stroke. This designation would be extremely helpful to clinicians in deciding which patients can safely forgo anticoagulation therapy, Dr. Singer and his associates said. Similarly, the ATRIA score was markedly better than the other two risk schemes at discriminating risk for severe, as compared with minor, stroke events. This would be very helpful to clinicians in deciding which patients are most in need of anticoagulation therapy, they said. Dr. Singer reported ties to Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Johnson & Johnson, and Pfizer.

Abstract 22: Accuracy of Perceived Stroke Risk among Young to Middle-Aged Rural African Americans

Background & Purpose: Stroke has increased among young adults, which is concerning for African Americans (AA) who have more severe stroke-related outcomes than Caucasians. Since stroke is more common in older adults, younger adults may not recognize stroke as a threat or take action to reduce modifiable stroke risk factors. The purpose of this study was to examine accuracy of perceived stroke risk by comparing perceived risk of future stroke with actual risk of stroke among rural AA aged 19-54 years. Methods: A cross-sectional design was used and AA were recruited from rural Alabama. Perceived risk of stroke was measured using a single-item subjective rating of 10-20 year risk of stroke and factors participants attributed to their risk were also explored. Actual stroke risk was calculated based on the presence of eight risk factors: history of hypertension, high cholesterol, diabetes, atrial fibrillation, cigarette smoking, family history of stroke, BMI > 30 and lack of exercise. Based on the number of actual risk factors, participants were categorized into one of three groups; no risk, low risk (1-2 factors); or moderate-high risk (> 3 risk factors). Results: Participants (N=66) had a mean age of 43.3+9.4 years, were 71% female, with at least 12 years of school (89%), and unemployed (62%). The majority (66%) perceived their risk of future stroke as no or low risk. However, actual risk factors averaged 2.97+1.63 out of 8 with 59% in the moderate-high actual stroke risk category. In comparing perceived versus actual risk, 44% underestimated, 47% were accurate, and 9% overestimated their risk. Sample characteristics were not associated with accuracy. Most (69%) participants with hypertension (n= 35); 80% of cigarette smokers (n= 25), 93% of diabetics (n= 13) and 88% of overweight/obese participants (n= 49) did not identify their personal risk factors as contributing to their risk of future stroke. Conclusion: Despite the number of risk factors observed, participants did not perceive a high risk of future stroke, almost half underestimated their risk of stroke, and few recognized personal risk factors. Strategies to address risk misperceptions should be explored to improve accuracy of perceived stroke risk and facilitate tailoring of interventions to reduce stroke.

Stroke risk estimation across nine European countries in the MORGAM project

BackgroundPrevious tools for stroke risk assessment have either been developed for specific populations or lack data on non-fatal events or uniform data collection. The purpose of this study was to...

004 Predicting early and late mortality in patients presenting for STEMI with CHADS2 score

Based on age and simple history data of patients, the CHADS2 score provides accurate assessment of the 1 year risk of stroke in the setting of atrial fibrillation. We sought to assess the hypothesis that the CHADS2 score may be as useful in the setting of STEMI, in comparison with more complex validated scores. We assessed CHADS2, TIMI and GRACE risk scores, in 697 consecutive patients admitted for STEMI within 24 hours after the onset of the symptom. In-hospital, 30-days, 6-months and 1-year mortality rates were assessed according to the CHADS score (0 to 6). Low, intermediate and high risk patients were identified by different scores : <2, 2-3, >3 for CHADS; <4, 4-6, >6 for TIMI; <126, 126-154, > 154 for GRACE respectively. The cumulative in-hospital, 30-day, 6-month and 1-year mortality rates were 5.3%, 6.3%, 7.8% and 8.8% respectively. CHADS2 score was significantly associated with all mortality rates (p<0.0001) with ORs of 2.2 (95%CI 1.7-2.8), 2.1 (95%CI 1.6-2.7), 2 (95%CI 1.6-2.7), and 2 (95%CI 1.6-2.6) per score point respectively. The concordance between the scores in predicting 1-year mortality was fair as shown by kappa values of 0.53 and 0.50 for CHADS2 versus the 2 other and 0.53 between GRACE and TIMI scores (Figure). CHADS2 score is highly correlated to early and late mortality after STEMI. The risk prediction by this simple purely clinical and available at first medical contact score, is concordant with more sophisticated scores.

Non-valvular atrial fibrillation and stroke prevention. National Blood Pressure Advisory Committee of the National Heart Foundation.

Atrial fibrillation (AF) affects 5% of people older than 65 years. Among patients with AF, the risk of stroke averages about 5% per year. The risk of stroke increases cumulatively with increasing age, previous transient ischaemic attack or stroke, hypertension, diabetes, impaired left ventricular function and a large left atrium. Management aims to identify and treat the underlying cause, control the ventricular rate, restore and maintain sinus rhythm, and minimise the risk of stroke. Warfarin reduces the risk of stroke by about two-thirds, and aspirin by about one-fifth. The risk of anticoagulant-associated haemorrhage increases with serious concomitant disease, and with poorly controlled hypertension and poorly controlled anticoagulation. All patients with chronic AF should be considered for oral anticoagulant therapy, and the decision based on the balance between the risks of thromboembolism and bleeding. The recommended INR (international normalised ratio) is 2.0-3.0. Treating 1,000 "average" AF patients (ie, those with a 5% per year risk of stroke) with warfarin prevents about 30 strokes and causes at least two episodes of major haemorrhage each year. Treating 1,000

Risk, Causes and Prevention of Ischemic Stroke in Elderly Patients with Symptomatic Internal Carotid Artery Stenosis

91 Background. Atherosclerosis is an important cause of stroke in the elderly. Carotid endarterectomy (CE) benefits patients with 70–99% symptomatic internal carotid artery (ICA) stenosis, less for patients with 50–69% stenosis. The benefit of CE in elderly patients (≥75 years) requires evaluation. Methods. Elderly patients with symptomatic ICA stenosis were compared to those 65–74 years and &lt;65 years in regards to baseline characteristics, risk of ipsilateral ischemic stroke at 2 years by degree of stenosis and treatment group and risk of ischemic stroke in the territory of an asymptomatic contralateral carotid artery. Results. The risk of ipsilateral ischemic stroke was highest in the medically-treated elderly regardless of the degree of stenosis. Among 659 patients with 70–99% stenosis, the absolute risk reduction (ARR) of ipsilateral ischemic stroke by CE was 28.9% for patients ≥75 years (N=71), 15.1% for 65–74 years (N=285) and 9.7% for &lt;65 years (N=303). Among patients with 50–69% stenosis, the ARR was significant only in those ≥75 years (N=145) with an ARR of 17.3%. The perioperative risk of stroke and death at any degree of stenosis was less in the elderly: 5.1% for patients ≥75 years, 5.4% for 65–74 years and 7.8% for &lt;65 years. The numbers of patients ≥75 years with 70–99% and 50–69% stenosis needed to treat (NNT) by CE to prevent one ipsilateral stroke within 2 years were 3 and 6, respectively. For 60–99% asymptomatic contralateral ICA stenosis, the 2 year risk of stroke was 7.8% in patients ≥75 years and 7.4% in those &lt; 75 years. The risk of ischemic stroke at 5 years in the territory of a 60–99% asymptomatic ICA stenosis was higher in patients ≥75 years (24.8%) than in patients &lt;75 years (14.9%). Conclusions. In the prevention of ipsilateral ischemic stroke, elderly patients with 50–99% symptomatic carotid stenosis benefited more from CE than younger patients. To achieve this benefit, patients must be carefully selected, excluding those with other life threatening illnesses.

Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1066 patients from 3 clinical trials.

Clinical features that consistently predict ischemic stroke in patients with nonvalvular atrial fibrillation have been identified, while echocardiographic risk factors are less well defined. To determine whether the results of transthoracic echocardiography add independent information to the clinical risk factors for stroke in patients with atrial fibrillation. Transthoracic echocardiographic findings and clinical features from 1066 patients with atrial fibrillation assigned to placebo or control in 3 randomized trials (Boston Area Anticoagulation Trial for Atrial Fibrillation, Stroke Prevention in Atrial Fibrillation I Study, and Veterans Affairs Prevention in Atrial Fibrillation Study) were correlated with subsequent ischemic stroke by multivariate analysis. The mean + SD age of patients was 67 +/- 10 years, 78% were men, 55% had a history of hypertension, 19% had a history of diabetes, 7% had a previous transient ischemic attack or stroke, and 27% had a history of heart failure. During a mean follow-up of 1.6 years, 78 ischemic strokes occurred (annual rate, 4.7%). Moderate to severe left ventricular systolic dysfunction shown via 2-dimensional echocardiography was a strong independent predictor of stroke (relative risk, 2.5; P<.001) in the 1010 patients in whom echocardiographic values for left ventricular function were available. Left atrial diameter by M-mode echocardiography did not predict stroke (relative risk, 1.02/mm; P = .10). Of 163 patients categorized as low risk based on clinical features (annual stroke rate, 0.8%; 95% confidence interval, 0.2%-3.0%), 10 had moderate to severe left ventricular dysfunction shown via 2-dimensional echocardiography and a 9.3% per year risk of stroke (95% confidence interval, 1.3%-66%). Conversely, 728 of the 847 patients at high risk for stroke based on clinical criteria had normal or mildly abnormal left ventricular function; their stroke rate was 4.4% (95% confidence interval, 3.4%-5.8%). Left ventricular systolic dysfunction shown via 2-dimensional transthoracic echocardiography independently predicts risk of stroke in patients with atrial fibrillation. Echocardiography may prove most useful in a small group of patients who have a low risk of stroke according to clinical factors.