American Heart Association

Declining Treatment Gaps in the United States

Sohei Yoshimura, MD, PhD
@sohei_y

Otite FO, Saini V, Sur NB, Patel S, Sharma R, Akano EO, Anikpezie N, Albright K, Schmidt E, Hoffman H, et al. Ten-Year Trend in Age, Sex, and Racial Disparity in tPA (Alteplase) and Thrombectomy Use Following Stroke in the United States. Stroke. 2021;52:2562-2570. 

Stroke is a common disease, but there have been reports of common stroke treatment disparities related to several factors, such as age, gender, and race. This study evaluated national trends in age-, sex-, and race-specific use of IV tPA and mechanical thrombectomy (MT), the most important quality indicators for standardized stroke treatment. The data was obtained from National Inpatients Samples (NIS), the largest publicly available inpatient healthcare database in the United States.  The authors used ICD-9-CM and ICD-10-MC/procedure coding system to identify exposures and outcomes. This study revealed that the overall frequency of IV tPA and MT utilization in the U.S. increased in all age, sex, and race groups over the last decade. The pace of the increase was more pronounced in ≥80 year old patients and in Black and Hispanic patients, leading to a decline in age- and race-associated treatment gaps over time. The faster increase of IV rPA usage in women also led to narrowing of sex-related treatment gaps.

By |November 29th, 2021|clinical|0 Comments

Article Commentary: “Demographic Disparities in Proximity to Certified Stroke Care in the United States”

Parth Upadhyaya, DO

Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke. 2021;52:2571–2579.

In recent years, the widened net for time-dependent interventions of acute stroke finds a counterpoint with irregular geographic distribution of capable certified stroke centers. With this comes unequal access for varied demographics. The authors aim to identify these gaps to better focus resources on disparities as stroke care continues to evolve.

By using United States Census Bureau data, the authors first determined the location of population density centroids of each census tract (U.S. Census Bureau) and the three nearest certified stroke centers by linear distance. The shortest road distance designated the nearest stroke center to each given census tract. Age, race, ethnicity, insurance status and income for each census tract, in addition to urban versus nonurban location, were identified in relation to stroke centers. Urban was defined by population density of 1000 people per square mile with a minimum of 2,500 people. By creating a hypothetical urban and nonurban reference tract, confounding factors were controlled, and before-mentioned characteristics elucidated.

By |November 24th, 2021|clinical|0 Comments

Racial Discrepancy in Blood Pressure Control

Nurose Karim, MD

Akinyelure OP, Jaeger BC, Moore TL, Hubbard D, Oparil S, Howard VJ, Howard G, Buie JN, Magwood GS, Adams RJ, et al. Racial Differences in Blood Pressure Control Following Stroke: The REGARDS Study. Stroke. 2021.

Hypertension (HTN) is defined as systolic blood pressure (SBP) >140 mm Hg and diastolic blood pressure (DBP) >90 mm Hg in patients without prior stroke. It is one of the leading causes of primary and recurrent strokes. HTN is the third leading cause of death in women and fifth leading cause in men. As it is one of the modifiable risk factors for future strokes, in 2017, the American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline set a lower BP target, SBP/DBP <130/80 mm Hg for patients with prior stroke. This study examines racial differences in BP control following a stroke using the 2017 ACC/AHA BP guideline thresholds and utilizing the data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. This study reviewed participants taking antihypertensive medication who did (n=306) and did not (n=7,693) experience an adjudicated stroke between baseline (2003-2007) and a second study visit (2013-2016).

By |November 23rd, 2021|clinical|0 Comments

Article Commentary: “Impact of Delirium on Outcomes After Intracerebral Hemorrhage”

Hannah Roeder, MD, MPH

Reznik ME, Margolis SA, Mahta A, Wendell LC, Thompson BB, Stretz C, Rudolph JL, Boukrina O, Barrett AM, Daiello LA, et al. Impact of Delirium on Outcomes After Intracerebral Hemorrhage. Stroke. 2021.

Delirium is defined by DSM-5 criteria as a change in functional status marked by disturbances in attention and awareness, which develop acutely, fluctuate, and are due to an underlying toxic or medical condition. Delirium frequently affects patients hospitalized with stroke. Its occurrence is associated with worse outcomes; however, there is no effective treatment. In the absence of effective treatment, can we still improve functional outcomes among stroke patients who develop delirium?

In the current study, Reznik and colleagues aim to define the extent of in-hospital delirium following intracerebral hemorrhage (ICH) and identify direct and indirect impacts on patient outcomes. In developing their hypotheses, they recognized that delirium may influence prognostication, intensity of care, and rehabilitation of neurocritical care patients. The authors explored several hypotheses, including that delirium portends worse outcomes, that delirium leads to lower likelihood of discharge to an inpatient rehabilitation facility (IRF), and that discharge disposition mediates poor outcomes. They also explored differences based on whether delirium resolves or persists at hospital discharge.

By |November 22nd, 2021|clinical, outcomes|0 Comments

AHA Scientific Sessions: “Updates in Stroke: Careers & Future Directions in Vascular Neurology”

Meghana Srinivas, MD

AHA Scientific Sessions 2021
November 13–15, 2021

Session: “Updates in Stroke: Careers & Future Directions in Vascular Neurology”
Panelists:
Drs. Anjail Sharrief, Ashutosh Jadhav, Louise McCullough, Alicia Zhao

This session kickstarted by highlighting the timeline to consider a career path as a neurology trainee and why it is important to do a fellowship. In current times, there is rapid growth in the field of medicine, and with this, there is an increased demand to have specialists, and hence choosing a fellowship is important. The panelists discussed extensively a career in vascular neurology and why we need more vascular neurologists in practice. There was a shocking revelation showing the dearth of vascular neurologists as compared to our counterparts, cardiologists. The ratio of graduating stroke neurologists to that of cardiologists is ~1:10; however, the disease burden is not proportionate. Why is this? A part of this could be attributed to the amount of exposure we get in acute stroke management during our training as residents, making us comfortable to manage these patients and hence inclined towards either an inpatient or outpatient setting without a formal fellowship. But wait, there is more to it: The panelists gave us an insight into poststroke care and management, which is also equally important. They discussed in detail patient care both in acute and in the post-discharge period, emphasizing that a fellowship is important, as it gives you an opportunity for continuity of care even at the community level.

Are NIHSS Score and Age More Than Just Numbers?

Meghana Srinivas, MD
@SrinivasMeghana

Bres-Bullrich M, Fridman S, Sposato LA. Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke. 2021;52:2846–2848.

In this article by Maria Bres-Bullrich et al., the authors discuss the utilization of prognostic tools in determining functional outcomes in patients with acute ischemic due to an anterior circulation large vessel occlusion (LVO) with or without mechanical thrombectomy (MT). Mechanical thrombectomy (MT) is the standard of care for patients presenting with anterior circulation LVO. However, not all patients who receive MT benefit in a similar way. Stroke severity and age, which are readily available, are strong determinants of outcomes in patients receiving MT in clinical trials, and they heavily influence the decision to perform MT. However, there is a possible discrepancy between observational studies and clinical trials, with the former showing older age group (≥80 years) is associated with lower likelihood of shift to better outcomes and higher rates of death. In real-world practice, the interplay between stroke severity and age, as well as the relative weight of each variable on outcomes, are poorly understood.

CHIP and Stroke: Risk for Cerebrovascular Diseases Dwells in the Bone Marrow

Aurora Semerano, MD
@semerano_aurora

Bhattacharya R, Zekavat SM, Haessler J, Fornage M, Raffield L, Uddin MM, Bick AG, Niroula A, Yu B, Gibson C, et al. Clonal Hematopoiesis Is Associated With Higher Risk of Stroke. Stroke. 2021.

Clonal hematopoiesis of indeterminate potential (CHIP) consists of a clonal expansion of circulating blood cells that arises from somatic mutations in hematopoietic stem cells. This condition usually does not entail abnormal blood cell counts and is common in older individuals, since it has been detected by DNA sequencing in >10% of people aged 70+ years. While carrying a relatively modest risk of developing hematological malignancy, from 2014 onwards CHIP has been unexpectedly and increasingly recognized as an independent, non-traditional risk factor for cardiovascular diseases and atherosclerosis, underlying the important interplay between aging, inflammation, and cardiovascular health. Interestingly, CHIP is determined by mutations in a handful of genes, which are currently under active investigations in experimental models. For example, accelerated atherosclerosis and increased release of inflammatory cytokines have been found in mice that bear TET2-deficient leukocytes. The relationship between CHIP and stroke risk was first reported in 2014 by Jaiswal et al.1 Indeed, by analyzing two cohorts of ~3000 patients, the presence of a somatic mutation was associated with an increased risk of ischemic stroke with a hazard ratio of 2.6 (95% CI, 1.4 to 4.8).

In the article by Bhattacharya et al. recently published in Stroke, the authors aimed at expanding the knowledge about the association between CHIP and risk of cerebrovascular events, taking into account both ischemic and hemorrhagic strokes, as well as stroke etiology. A total of 86,178 individuals from 8 prospective cohorts or biobanks were included. The overall prevalence of CHIP at baseline was 6%. CHIP was associated with an increased risk of total stroke (hazard ratio, 1.14; 95% CI, 1.03–1.27). Unexpectedly, this relationship was primarily driven by a 24% increased odds of hemorrhagic stroke, particularly subarachnoid hemorrhage. Though CHIP was not found to be associated with ischemic stroke overall, in exploratory analyses from one female patient cohort, CHIP was more strongly associated with small vessel disease than with large artery atherosclerosis or cardioembolic etiologies. When analyzing mutations in specific CHIP genes, TET2 showed the strongest association with total stroke and ischemic stroke, whereas DMNT3A and TET2 were each associated with increased risk of hemorrhagic stroke.

To TEE or Not to TEE?

Kevin O’Connor, MD

Thomalla G, Upneja M, Camen S, Jensen M, Schröder J, Barow E, Boskamp S, Ostermeier B, Kissling S, Leinisch E, et al. Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study. Stroke. 2021.

About one fifth of acute ischemic strokes and transient ischemic attacks stem from cardioembolism. Although cardiac ultrasound is generally recommended as a reasonable diagnostic study, there is ongoing debate on the utility of transthoracic echocardiography (TTE) versus transesophageal echocardiography (TEE). In practice, TTE may be preferred as it is less invasive and easier to obtain but at the expense of decreased sensitivity when evaluating for some pathologies involving the aorta and left atrium. Thomalla et al. designed the Comparative Effectiveness Study of Transthoracic and Transesophageal Echocardiography in Stroke (CONTEST) study to compare the diagnostic yield of treatment-relevant findings (i.e., findings sufficient to justify a change in medication, intervention, or surgery) of TTE and TEE in patients with acute ischemic stroke, transient ischemic attack, or retinal ischemia of undetermined cause. Despite early study termination due to funding cessation, 494 patients were enrolled with 454 undergoing both TTE and TEE.  

The Tissue Clock: “Prediction of Stroke Infarct Growth Rates by Baseline Perfusion Imaging”

Tolga D. Dittrich, MD

Wouters A, Robben D, Christensen S, Marquering HA, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Dippel DWJ, Majoie CBLM, Schonewille WJ, et al. Prediction of Stroke Infarct Growth Rates by Baseline Perfusion Imaging. Stroke. 2021.

For the acute treatment of ischemic stroke with endovascular therapy (EVT), the time between symptom onset and therapy initiation is considered crucial so far. However, the trend has shifted in recent years from rigid time windows to more individualized, advanced imaging-based, patient selection for EVT.

CT-based perfusion imaging (CTP) has gained importance in identifying individuals with potentially salvageable brain tissue. Automated perfusion assessments using specialized software (e.g., RAPID) are frequently employed in clinical practice to calculate mismatch volume. For the analysis, two key parameters are defined: the relative cerebral blood flow (rCBF) below 30% as a reflection of the ischemic core volume and the delay to the maximum of the residue function (Tmax) of more than 6 seconds, which defines critically hypoperfused brain tissue. The final infarct volume often corresponds with the ischemic core volume determined at baseline in cases of successful reperfusion. In patients without reperfusion, the size of the hypoperfused brain tissue can be used to predict the final infarct size. However, accurate prediction of final infarct size, especially as a function of reperfusion status, is not possible using these conventional CTP analyses as they only represent snapshots at the time of examination.

Article Commentary: “SLEAP SMART (Sleep Apnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke)”

Dixon Yang, MD

Boulos MI, Kamra M, Colelli DR, Kirolos N, Gladstone DJ, Boyle K, Sundaram A, Hopyan JJ, Swartz RH, Mamdani M, et al. SLEAP SMART (Sleep Apnea Screening Using Mobile Ambulatory Recorders After TIA/Stroke): A Randomized Controlled Trial. Stroke. 2021.

Obstructive sleep apnea (OSA) is common in stroke/transient ischemic attack (TIA) survivors. Untreated OSA can increase risk of cardiovascular disease, including recurrent stroke, and lead to worse functional outcomes. Yet, OSA remains underdiagnosed after stroke. Barriers to diagnosis may include patient inconvenience and cost of an in-laboratory polysomnography (iPSG); therefore, Boulos et al. sought to compare the diagnostic performance of a home sleep apnea test (HSAT) in SLEAP SMART.

The primary objective of SLEAP SMART was to determine the proportion of OSA diagnosed at 6 months after stroke/TIA using HSAT as compared to iPSG. Secondarily, the trial sought to evaluate if screening for OSA with HSAT when compared to iPSG led to increased CPAP prescription, reduced daytime sleepiness, improved sleep-related quality of life, improved functional outcomes, improved patient experience with the sleep test, and cost-effectiveness for the diagnosis of OSA. Participants were recruited from 2015-2017 at a single Canadian center who had imaging-confirmed stroke or stroke-physician diagnosed TIA within the last 6 months. Exclusion criteria were a prior diagnosis of OSA, current CPAP use, comorbidities or use of medical devices that could compromise HSAT accuracy, barriers to complying with CPAP therapy, and significant physical or cognitive impairment. Eligible patients were randomized 1:1 to iPSG or HSAT. OSA was defined as apnea-hyponea index ≥15 or apnea-hyponea index ≥5 with a lowest oxygen desaturation ≤88%. Primary outcomes were compared using intention-to-treat analysis.

By |November 10th, 2021|clinical|0 Comments