American Heart Association

Monthly Archives: September 2019

Article Commentary: “Obesity-Associated Organ Damage and Sympathetic Nervous Activity: A Target for Treatment?”

Adeola Olowu, MD

Lambert EA, Esler MD, Schlaich MP, Dixon J, Eikelis N, Lambert GW. Obesity-Associated Organ Damage and Sympathetic Nervous Activity: A Target for Treatment? Hypertension. 2019;73:1150–1159.

The authors of this review focused on obesity and a potential target for treatment. Obesity and increased body mass index are risk factors for diseases such as stroke, cardiovascular disease, and other medical conditions. This brief review focused on cardiovascular studies, studies demonstrating an association between weight gain with blood pressure, cardiovascular abnormalities, renal function, and endothelial dysfunction and its relationship with biochemical sympathetic nervous activity.

Being overweight or obese is a growing medical condition worldwide. Obesity is unique to other cerebrovascular risk factors because it may be the sole risk factor an individual may have for quite some time. However, the lack of other cerebrovascular risk factors such as hypertension and diabetes does not make being overweight or obese harmless. The studies reviewed showed hypertension prevalence to be at least 16% higher in the obese population compared to the normal-weight population in the United States. Pre-hypertension was found in approximately 40% of obese men and 30% in obese women in China. Observational studies demonstrated elevated plasma norepinephrine and increased MSNA with weight gain.

By |September 30th, 2019|clinical, treatment|0 Comments

When Does Treatment Advancement Mean “It’s Time”?

Richard Jackson, MD

Leira EC, Muir KW. EXTEND Trial: Towards a More Inclusive But Complex Thrombolysis. Stroke. 2019;50:2637–2639.

Leira and Muir evaluated the EXTEND trial in comparison to previous trials of IV thrombolysis in the >4.5 hour window, including the DIAS trials, DEDAS, EPITHET, and the more recent WAKE-UP trial. The latter trials were all MRI/MR-Perfusion based evaluation except WAKE-UP, which was DWI/FLAIR, in contrast to EXTEND, which was CT/CT-Perfusion.

EXTEND included patients with NIHSS 4-26 with a viable tissue ratio of 1.2 or <10 mL difference and <70 mL core and was terminated prematurely with the release of the DEFUSE-3 data due to the possible eligibility of some of the trial population for thrombectomy with the inclusion of approximately 70% of patients with a large vessel occlusion and median NIHSS>12. 

In EXTEND, a higher proportion of patients had recanalization, major early neurologic improvement, independent recovery mRS 0-2 at 90 days, but an increased rate of symptomatic ICH (6.2% vs 0.9%). The conclusion was that the trial “consolidates the concept of determining treatment eligibility based on physiological imaging rather than noncontrast CT and the clock” and that “these advances clearly expand the options for intravenous thrombolysis for late arrivals and strokes of uncertain time of onset.” 

I was present and excited at the delivery of the results of the trial at the International Stroke Conference 2019. The question for all of us stroke directors creating protocols is, “Is it time?”

By |September 27th, 2019|clinical|0 Comments

Could We Use NT-ProBNP as a Reliable Tool to Keep Searching for Hidden Atrial Fibrillation in Patients with Cryptogenic Stroke?

Reyes de Torres Chacon, MD

Kneihsl M, Gattringer T, Bisping E, Scherr D, Raggam R, Mangge H, et al. Blood Biomarkers of Heart Failure and Hypercoagulation to Identify Atrial Fibrillation–Related Stroke. Stroke. 2019;50:2223–2226.

Several biomarkers are being tested to help us point to which patients with cryptogenic stroke are most likely to have hidden atrial fibrillation as the real etiology of the stroke. Some of these biomarkers are echocardiography-based as left atrial enlargement, others are rhythm-based such as a high number of atrial premature beats or atrial runs, and others are laboratory-based as heart failure indicators like Nt-ProBNP, D-Dímer, or antithrombin-III. All these indicators could point out which patient we should continue to perform additional tests for the detection of atrial fibrillation.

In this study, it was shown that the blood values of NT-ProBNP ≥505 pg/ml have a high sensitivity (93%) and specificity (72%) to detect heart-related causes of stroke, mainly atrial fibrillation. Even in patients with cryptogenic stroke, high levels of NT-ProBNP were associated with detection of hidden AF at follow up (levels below 505 pg/ml had a negative predictive value of 98%). Other blood biomarkers related to myocardial damage and hypercoagulability, such as D-dimer or antithrombin-III, also show an association with AF-related stroke, but with lower sensitivity and specificity (D-dimer cutoff value of  0.70 μg/ml, sensitivity of 61%, and specificity of 58%; 89% decrease in AT-III value has a sensitivity of 53% and specificity of 69%).

By |September 24th, 2019|clinical|0 Comments

The Trials of tPA

Rachel Forman, MD

Haslett JJ, Genadry L, Zhang X, LaBelle LA, Bederson J, Mocco J, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019

When I read the title of this article, the first thing that came to mind was the bleeding risk associated with tPA. After all, we carefully read through the tPA contraindications checklist making sure we will not cause harm to our patients. It turns out that there is a lot more to worry about! 

In the article “Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke,” Haslett et al. discuss characteristics of malpractice cases related to acute stroke management. 

It was helpful that the authors first defined some legal terms, specifically that “to prove medical malpractice occurred, a plaintiff must show that during the course of treatment, the physician deviated from the standard of care as defined by the medical community, and that caused injury to the patient.”

Door In/Door Out Not as Important for DAWN Patients

Richard Jackson, MD

Aghaebrahim A, Jadhav AP, Hanel R, Sauvageau E, Granja MF, Zhang Y, et al. Outcome in Direct Versus Transfer Patients in the DAWN Controlled Trial. Stroke. 2019;50:2163–2167.

Amin Aghaebrahim et al. analyzed the DAWN data for outcomes related from direct versus transfer thrombectomy interventions to find that outcomes were similar. The only difference between the Table 1 characteristics in the groups was a 15% IV-tPA treatment in the transfer group and longer door to reperfusion time in the direct to thrombectomy group.  

The authors conclude that the DAWN patients are high in good collaterals and slow progressors by a lack of significance between mRS between transfer and direct thrombectomy patients. This is significant information for the stroke directors of primary stroke centers such as myself creating the protocols for transfer for thrombectomy and the new evaluation guidelines for door-in/door-out time evaluations, as they may not be as crucial as for the 0-6 hour window for fast progressors.

By |September 20th, 2019|clinical|0 Comments

The Chicken or the Egg? Functional Recovery from Intracerebral Hemorrhage in the Setting of Cerebral Small Vessel Disease

Charlotte Zerna, MD, MSc

Uniken Venema SM, Marini S, Lena UK, Morotti A, Jessel M, Moomaw CJ, et al. Impact of Cerebral Small Vessel Disease on Functional Recovery After Intracerebral Hemorrhage. Stroke. 2019

Cerebral small vessel disease has been shown to lead to worse clinical outcomes in both ischemic and hemorrhagic stroke, affect post stroke neuroplasticity, and thus impair cerebral network reorganization that is needed after neuronal injury. Several imaging features of cerebral small vessel disease exist and can be measured on both magnetic resonance imaging and computed tomography. In this study, the authors aimed to investigate the association of two of these imaging factors (leukoaraiosis measured as reduced area of x-ray attenuation on CT and brain atrophy measured as volume loss not related to a specific macroscopic focal injury such as trauma or infarction) with functional outcome at 90 days and a recovery trajectory marker (difference between modified Rankin Scale score at discharge and day 90).

By |September 18th, 2019|clinical|0 Comments

Article Commentary: “Urinary Sodium Excretion, Blood Pressure, and Risk of Future Cardiovascular Disease and Mortality in Subjects Without Prior Cardiovascular Disease”

Adeola Olowu, MD

Welsh CE, Welsh P, Jhund P, Delles C, Celis-Morales C, Lewsey JD, et al. Urinary Sodium Excretion, Blood Pressure, and Risk of Future Cardiovascular Disease and Mortality in Subjects Without Prior Cardiovascular Disease. Hypertension. 2019;73:1202–1209.

The authors from the Institute of Cardiovascular and Medical Sciences, Institute of Health and Wellbeing, and Women’s Health Research Division conducted a prospective cohort study on UK Biobank participants to determine if a common lab value — Urinary Sodium Excretion — could affect mortality or the development of cardiovascular disease determine future cardiovascular disease.

A total of 457,484 participants were prospectively evaluated for the development of cardiovascular disease over approximately 7 years. These participants did not have any cardiovascular conditions such as heart disease, hypertension, or diabetes.

By |September 17th, 2019|clinical|0 Comments

Article Commentary: “Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5”

Mausaminben Hathidara, MD

Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, et al. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5. Stroke. 2019;50:880–888.

Mechanical thrombectomy (MT) for patients with large vessel occlusion of anterior circulation, presenting within 6 hours from symptoms onset and ASPECT score 6-10, is the standard of treatment and recommended by the American Stroke Association. However, very limited data is available regarding safety and efficacy for such treatment modalities for patients with ASPECT score 0-5. This multicenter retrospective non-randomized study analyzed MT outcome for patients with ASPECT score 0-5 at 90 days. Primary outcome of the study was favorable outcome (mRS 0-3) at 90 days and secondary outcome was mRS 0-2 at 90 days, major early neurological improvement (defined as change in NIHSS >8 points, 24 hr NIHSS<1), all-cause mortality at 90 days and symptomatic intracerebral hemorrhage (sICH). 1532 patients who had confirmed anterior circulation LVO including intracranial ICA, ICA T/L, M1, M2, tandem occlusion and ASPECT score available on either CT (910/1532) or MRI (600/1532) were included in the final analysis. TICI score and ASPECT score were determined by an independent research fellow at each site. 90 days mRS was obtained by a physician or trained certified nurse. NIHSS at admission and 24 hours was performed by a stroke neurologist.

By |September 16th, 2019|clinical|0 Comments

Stenting in the Vertebral Artery? Best Extracranial

Elena Zapata-Arriaza, MD

Markus HS, Harshfield EL, Compter A, Kuker W, Kappelle LJ, Clifton A, et al. Stenting for symptomatic vertebral artery stenosis: a preplanned pooled individual patient data analysis. Lancet Neurol. 2019;18:666-673.

Symptomatic vertebral artery stenosis is related to an increased risk of recurrent ischemic stroke. However, the superiority of endovascular treatment over the medical approach in vertebral stenosis is not supported by solid scientific evidence, so it’s difficult to determine which therapeutic option is better. Markus et al. aimed to define whether vertebral stenting is more effective than medical treatment for symptomatic vertebral stenosis, using individual patient data pooled from trials published up to now.

After reviewing randomized controlled trials comparing stenting vs medical treatment for vertebral stenosis, the authors included the VIST, VAST and SAMMPRIS trials in pooled analysis. Data from the intention-to-treat analysis were used for all studies. Primary outcome was any fatal or non-fatal stroke during follow-up. Secondary outcomes were posterior circulation stroke, any stroke or transient ischaemic attack, stroke or death, and periprocedural stroke or death, which was defined as stroke or death within 30 days of randomisation. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses.

By |September 13th, 2019|clinical|0 Comments

Article Commentary: “Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery”

Parneet Grewal, MD

Wilcox T, Smilowitz NR, Xia Y, Berger JS. Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery. Stroke. 2019;50:2002–2006.

Perioperative stroke has been linked to increased mortality and morbidity in patients undergoing surgical procedures. A number of cardiovascular risk assessment tools, such as Revised Cardiac Risk Index (RCRI)1, the myocardial infarction or cardiac arrest (MICA) calculator1, the American College of surgeons surgical risk calculator (ACS-SRC), and Mashour et al. risk score,2 have been published to predict perioperative complications. CHADS2 and CHA2DS2-VASc risk scores have also been shown to improve prediction of postoperative stroke in patients undergoing cardiac procedures even in absence of atrial fibrillation3. In this retrospective study, Wilcox et al. aimed to compare the effectiveness of existing cardiovascular risk stratification scores in predicting risk of perioperative stroke after non-cardiac surgery.

By |September 11th, 2019|clinical|0 Comments