American Heart Association

Monthly Archives: August 2017

Statins and Carotid Artery Stenting

Tapan Mehta, MBBS, MPH

Hong JH, Sohn SI, Kwak J, Yoo J, Chang HW, Kwon OK, et al. Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting. Stroke. 2017

In this entry, I discuss a recent publication by Dr. Jeong-Ho Hong and colleagues regarding effectiveness of statin pretreatment on preventing the periprocedural complications of carotid artery stenting (CAS).

CAS as a procedure has evolved significantly in the past two decades. Previous studies have shown increased periprocedural complication risk with CAS compared to carotid endarterectomy (CEA). Invention of new endovascular devices, distal embolization protection systems and antiplatelet medications, along with increasing operator experience, have contributed in reduction of periprocedural complications. Recently published CREST trial data can be considered an important example of this. As there is already data available on statin pretreatment reducing periprocedural complication risk for CEA and percutaneous coronary intervention, this study importantly extends the possibility of benefit with pre-procedural statin use for patients undergoing CAS.

Baseline Blood Pressure and Intra-Arterial Therapy Outcomes

Brian Marcus, MD

Mulder MJHL, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PSS, Beumer D, et al. Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). Stroke. 2017

It is known that extremes in blood pressure lead to worse functional outcomes in stroke patients. This article by Mulder et al. looks to see if similar extremes in blood pressure lead to worse outcomes in patients receiving intra-arterial treatment. They performed a post hoc analysis of the MR CLEAN study in the Netherlands and measured blood pressure at baseline and before intra-arterial treatment and compared this with the patient’s modified Rankin scale at 90 days. In addition to looking at modified Rankin scale, the authors also looked to see how blood pressure prior to therapy was related to imaging findings, changes in the NIHSS, TICI score, and the Barthel index.

By |August 28th, 2017|clinical|0 Comments

Author Interview: George Ntaios, MD

George Ntaios

George Ntaios

A conversation with George Ntaios, MD, MSc (ESO Stroke Medicine), PhD, Assistant Professor of Internal Medicine, Department of Medicine, University of Thessaly

Interviewed by Stephen Makin, PhD, Clinical Lecturer at Glasgow University

They will be discussing the paper, “Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis,” being published in the September 2017 issue of Stroke.

Dr. Makin: Thank you for taking the time to talk to us.

Prof. Ntaios: Thank you for the invitation to discuss our study.

Dr. Makin: Could I begin by asking you to summarize your study and its findings?

Prof. Ntaios: We aimed to summarize all available evidence from high-quality real-world observational studies about the efficacy and safety of non-vitamin-K-oral-anticoagulants (NOACs) compared to vitamin-K-antagonists (VKAs) in patients with atrial fibrillation (AF). Based on 28 identified studies, we found that dabigatran, rivaroxaban and apixaban, as compared to VKAs, are associated with lower risk of intracranial haemorrhage and similar risk of ischemic stroke and ischemic stroke or systemic embolism; apixaban and dabigatran with lower risk of mortality; apixaban with fewer gastrointestinal and major haemorrhages; dabigatran and rivaroxaban with higher risk of gastrointestinal haemorrhage; and dabigatran and rivaroxaban with a similar rate of myocardial infarction.

Does Head Positioning Matter in Acute Stroke?

Philip Chang, MD

Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017

This article by Anderson et al investigates the role of supine bedrest positioning after acute stroke and weighed it against the risk of aspiration pneumonia. In this trial, 11,093 patients were randomized to supine or head-up (defined as at least 30 degrees head of bed elevation) initiated after hospital admission and maintained for 24 hours. The primary outcome was mRS scores at 90 days. The results of the article showed that people who were supine were less likely to maintain a supine position for 24 hours (87% vs. 95%, p<0.001), and there was no difference in mRS scores at 90 days. In addition, there were no significant differences in serious adverse events between the two groups, including the rates of aspiration pneumonia. The authors of the trial suggest that any modification of cerebral blood flow that may have occurred as a result of head positioning initiated within 24 hours was insufficient to reduce neurologic deficit associated with acute stroke.

By |August 21st, 2017|clinical|0 Comments

Optimal Timing of DWI for TIA

Hatim Attar, MD

Shono K, Satomi J, Tada Y, Kanematsu Y, Yamamoto N, Izumi Y, et al. Optimal Timing of Diffusion-Weighted Imaging to Avoid False-Negative Findings in Patients With Transient Ischemic Attack. Stroke. 2017

MRI scans are the gold standard imaging modality for diagnosing acute cerebrovascular injury. The purpose of performing them in Transient Ischemic Attack (TIA) patients is to determine presence of infarction, which lends information on prognosis and risk of recurrence. This novel Japanese study has investigated Diffusion Weighted Imaging (DWI) latency from symptom onset and false negative MRI scans in TIA patients. Shono et al have determined the optimal timing of obtaining MRI scans in TIA patients to limit false negative results.

By |August 16th, 2017|clinical|0 Comments

Stroke Risk Stratification in Non-Valvular Atrial Fibrillation — Validating CHA2DS2-VASc in an Asian Cohort

Gurmeen Kaur, MBBS
@kaurgurmeen

Kim T, Yang P, Uhm J, Kim J, Pak H, Lee M, et al. CHA2DS2-VASc Score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female) for Stroke in Asian Patients With Atrial Fibrillation: A Korean Nationwide Sample Cohort Study. Stroke. 2017

Non-valvular atrial fibrillation (AF) is a cause of at least 15-20% of strokes in the U.S., with a 5-times increased risk when compared to patients with no atrial fibrillation. The safety, efficacy and availability of oral anticoagulants, in addition to Vitamin K antagonists like warfarin, have made strokes secondary to atrial fibrillation virtually preventable. This has created a need for accurate Stroke Risk Assessment and Stratification.

Various stroke risk schemas over the years have included AFI/ SPAF (1994), CHADS2 (2001), Framingham (2003), NICE (2006) and the relatively recent CHA2DS2-VASc Score, also referred to as Birmingham 2009, that accounts for congestive heart failure, hypertension, 75 years of age and older (2 points), diabetes mellitus, previous stroke or transient ischemic attack (2 points), vascular disease, 65 to 74 years of age, female sex.

Kim et al study a total of 5855 oral anticoagulant (OAC) naïve patients with AF to determine whether the CHA2DS2-VASc score could be reliably used for the Asian population, because the validation studies were performed in an all-Caucasian cohort and various Asian studies have previously reported ethnic differences in the conventional stroke risk factors.

By |August 14th, 2017|clinical, prognosis|0 Comments

Author Interview: Robert G. Kowalski, MD, MS

Robert G. Kowalski

Robert G. Kowalski

A conversation with Robert G. Kowalski, MD, MS, Principal Investigator, Craig Hospital, and Assistant Clinical Professor of Neurology and PM&R, University of Colorado School of Medicine, about stroke following traumatic brain injury.

Interviewed by José G. Merino, MD, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “Acute Ischemic Stroke After Moderate to Severe Traumatic Brain Injury: Incidence and Impact on Outcome,” published in the July issue of Stroke.

Dr. Merino: Thank you for agreeing to the interview. Can you first briefly describe the methods and main findings of the analysis published in Stroke?

Dr. Kowalski: The study was a research collaboration between the Centers for Disease Control and Prevention (CDC) and the Traumatic Brain Injury Model Systems (TBIMS) program. It was led by researchers at Craig Hospital in Englewood, CO. Investigators studied more than 6,400 traumatic brain injury (TBI) patients over a 7.5-year period to evaluate risk factors for onset, incidence, and predictors of outcome in ischemic stroke occurring acutely after TBI. We found that 2.5% of individuals who experience a moderate to severe TBI also suffer an acute ischemic stroke (AIS) at the time of the injury. In half of these cases, the individuals experiencing stroke concurrent with brain trauma were age 40 or younger. Additionally, the study found the risk of acute ischemic stroke immediately following traumatic brain injury was 10 times the risk of ischemic stroke in the general population.

The Complex Relationship Between Statins and Intracerebral Hemorrhage Outcomes

Mark R. Etherton, MD, PhD

Siddiqui FM, Langefeld CD, Moomaw CJ, Comeau MJ, Sekar P, Rosand J, et al. Use of Statins and Outcomes in Intracerebral Hemorrhage Patients. Stroke. 2017

In this entry, I discuss a recent publication by Fazeel Siddiqui and colleagues regarding the use of statins and outcomes after intracerebral hemorrhage (ICH).

The current evidence suggests a complex relationship between serum cholesterol levels, statin use, and outcomes after ICH. Low serum cholesterol levels have been associated with increased incidence of ICH, as well as hematoma expansion. However, a prior meta-analysis demonstrated antecedent statin use was associated with decreased risk of mortality and increased likelihood of a good outcome after ICH (Jung et al. Int J Stroke. 2015). The authors, therefore, set out to investigate the relationship of statin use with ICH outcomes by evaluating 3-month disability, mortality, and hematoma size/expansion.

Author Interview: Philippa Lavallée, MD

A conversation with Philippa Lavallée, MD, Department of Neurology and Stroke Centre, Bichat University Hospital, about the importance of atypical symptoms in patients with TIA.

Interviewed by José G. Merino, MD, FAHA, Associate Professor of Neurology, University of Maryland School of Medicine.

They will be discussing the paper, “Clinical Significance of Isolated Atypical Transient Symptoms in a Cohort With Transient Ischemic Attack,” published in the June 2017 issue of Stroke.

Dr. Merino: Could you please briefly summarize the key findings and put them into context of what was known before you did the study?

Dr. Lavallée: Conventional wisdom considers that some transient symptoms such as diplopia, vertigo, dysarthria and even a sensory deficit limited to one limb or the face are not compatible with the diagnosis of TIA when they occur in isolation. Daily experience in the stroke unit and TIA clinic shows that it is not true. In our study, we enrolled 1,850 patients seen in our TIA clinic who had transient symptoms and found that 10% of the patients with stroke or TIA had one of these isolated atypical symptoms and that 10% of the patients with atypical symptoms had an acute infarct on brain MRI and 18% had an underlying disease that placed them at high risk of stroke recurrence.