American Heart Association

Monthly Archives: September 2019

Article Commentary: “Twenty-Four–Hour Reocclusion After Successful Mechanical Thrombectomy”

Wayneho Kam, MD

Marto JP, Strambo D, Hajdu SD, Eskandari A, Nannoni S, Sirimarco G, et al. Twenty-Four–Hour Reocclusion After Successful Mechanical Thrombectomy: Associated Factors and Long-Term Prognosis. Stroke. 2019

Early mechanical thrombectomy (MT) with successful recanalization leads to better outcomes following acute ischemic stroke. However, reocclusion of the treated vessel can occur in certain patients. It is important to identify those patients who are at high risk for such events so that measures can be taken to prevent potential neurological deterioration.

The study by Marto et al. published in Stroke in August 2019 sought to address this very topic. The authors examined data from the Acute Stroke Registry and Analysis of Lausanne cohort and included patients with anterior and posterior circulation strokes who were treated with MT, with resultant TICI 2B-3, and had 24-hour vascular imaging available. Reocclusion was defined as a new intracranial occlusion within an arterial segment that was recanalized at the end of MT.

By |September 10th, 2019|clinical|0 Comments

Article Commentary: “Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke”

Anusha Boyanpally, MD

Bailoor K, Shafie-Khorassani F, Lank RJ, Case E, Garcia NM, Lisabeth LD, et al. Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke. Stroke. 2019;50:1641–1647.

In-hospital mortality was significantly influenced by Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) (1). In 2007, the American Heart Association/American Stroke Association updated guidelines to avoid early DNR orders in the first 24 hours after ICH admission (2).

This is a single center study with a large minority population, which assessed calendar time trends of DNR orders after stroke from 2007 through 2016 in the ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients in different race-ethnic groups.

Only the first stroke events (both IS or ICH) were included, and patients with missing DNR status were excluded. Race-ethnicity was obtained both from medical records and from interview if missing from medical records. Time to DNR was calculated as time from stroke presentation to DNR order in hours. DNR orders were considered early if documented at or before 24 hours from the admission, and late if documented > 24 hours after admission. The authors have included neurodegenerative disease, history coronary artery disease, congestive heart failure, myocardial infarction, cancer, chronic obstructive pulmonary disease, end stage renal disease, cholesterol, hypertension, history of stroke, atrial fibrillation, diabetes, insurance status, and stroke severity. The authors initially used two types of 3-way interaction: one was between stroke type, calendar year, and binary DNR timing; another one was between race-ethnicity, calendar year, and DNR timing, but was removed due to lack of significance. So, eventually calculated 2-way interactions. DNR timing (early and late) was represented as dichotomous covariates.

By |September 9th, 2019|clinical|0 Comments

Article Commentary: “Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA”

Pamela Cheng, DO

Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018; 379:215-225.

The CHANCE trial had previously shown that dual antiplatelet therapy reduced the risk of recurrent stroke. However, the trial was conducted in a homogenous population in China; therefore, its applicability on an international population was uncertain. Enter the POINT trial.

A total of 4881 patients were enrolled at 269 international sites. Patients had to be at least 18 years of age and randomized within 12 hours after having an acute ischemic stroke with a score of 3 or less on the NIHSS or a high-risk TIA defined as ABCD2 score of 4 or more. Isolated numbness, isolated dizziness, and isolated visual changes were all excluded. Patients were randomly assigned in a 1:1 ratio to receive either clopidogrel plus aspirin or placebo plus aspirin. Patients receiving clopidogrel were given a 600 mg loading dose on day 1, followed by 75 mg daily from day 2 to day 90. Aspirin dose was determined by treating physician but was given in doses ranging from 50 mg to 325 mg daily. The primary outcome was the risk of composite ischemic stroke, myocardial infarction, or death from ischemic vascular causes. The primary safety outcome was the risk of major hemorrhage or death from hemorrhage.

By |September 6th, 2019|clinical|0 Comments