American Heart Association

prevention

Faith-based behavioral intervention in a Hispanic community shows modest benefit in promoting healthy lifestyle choices – Results of the SHARE trial

Danny R. Rose, Jr., MD

Brown DL, Conley KM, Sánchez BN, Resnicow K, Cowdery JE, Sais E, et al. A Multicomponent Behavioral Intervention to Reduce Stroke Risk Factor Behaviors: The Stroke Health and Risk Education Cluster-Randomized Controlled Trial. Stroke. 2015
 
Despite ample evidence regarding the importance modifiable risk factors for stroke prevention, optimal implementation of appropriate community interventions to promote positive lifestyle modifications remains uncertain. This is a particular concern for ethnic minority populations such as African Americans and Hispanic-Latinos, which have a higher prevalence of poorly controlled blood pressure and a greater burden of stroke. Given that these groups tend to have less favorable diet and exercise profiles and poorer access to preventative services, the need for developing culturally sensitive community preventative programs has been stressed. As a faith-based community intervention was feasible in studies centering on Protestant churches in the African-American community, Brown et al. used a similar approach, targeting 10 Catholic parishes within the Diocese of Corpus Christi, Texas.


The study randomized 10 Catholic churches and included 760 subjects, divided into control group and intervention groups. The intervention group received a one-year individual level program with culturally sensitive self-help materials focused on healthy eating, physical activity and blood pressure control, as well as newsletters, motivational interviewing calls and a 2 hour workshop on supportive peer counseling. Interventions were also done on the cluster level, promoting availability of lower sodium foods and fruits and vegetables at parish functions and programs to encourage healthy eating and physical activity. The control subjects received skin cancer awareness materials or sunblock at 3 and 9 months to maintain contact every three months, including assessments. Subjects were assessed during home visits for baseline and 12-month follow-up data, and with an interim 6-month telephone assessment. All three evaluations included validated questionnaires addressing dietary intake and physical activity. At baseline and 12 months, assessments included an average of recent blood pressure measurements, a fasting lipid panel, glucose and glycosolated hemoglobin, height and weight, waist circumference, a BP medication adherence question, and Self-Determination Theory measures. There were no significant baseline differences between the intervention and control groups. Over half of the subjects (56.3%) completed the baseline, 6 month and 12 month assessments, with about a quarter of subjects (25.8%) completing only the baseline and 12 month assessments; 28 subjects (3.7%) completed only the baseline and 6 month assessments.

There were significant improvements with the intervention for 2 of the 3 co-primary outcomes (decreased dietary sodium intake, p=0.04, and increased dietary fruit and vegetable intake, p=0.04). There was no impact on moderate or greater intensity physical activity. Similarly, there was no effect on systolic BP, a secondary outcome. Total dietary and saturated fat intake decreased in the intervention group, which was statistically significant after adjusting for age, sex, education and social desirability. There was no intervention effect for the remaining biological exploratory outcomes. Assessment of the Self-Determination Theory related outcomes, designed to measure perceived competence and motivation to adopt lifestyle modifications, showed a significant increase in perceived competence to eat more fruits and vegetables (p=0.01) and decrease in subjects reporting lack of motivation for dietary change (p=0.05). Self-reported adherence to the interventions was also assessed, with 74 percent of subjects completing at least one motivational call, 63 percent reporting having read at least one newsletter, 80 percent using the healthy eating guide and 55 percent using the exercise guide.

The outcomes of this study mirror similar community interventions finding a relatively modest effect of the intervention on risk factor modification. This and similar studies are subject to the inherent limitations of self-report and and the authors’ discussed their disappointment at the relatively low adherence rate in their study with respect to the interventions. Similar community and population-based risk factor intervention studies that utilize resource intensive, multi-faceted approaches to promote lifestyle modification tend to have only modest results, highlighting the complexity of the problem and what is likely a considerable amount of social and cultural underpinnings of poor diet and lack of physical activity. Additional studies are needed to identify and implement resource efficient programs for promoting healthier lifestyle choices. These programs should ideally involve a collaborative effort between healthcare providers, community leaders and government officials.

By |October 14th, 2015|prevention|0 Comments

Aggressive vascular risk factor modification did not reduce cognitive decline following ischemic stroke

Jay Shah, MD
 

Matz K, Teuschl Y, Firlinger B, Dachenhausen A, Keindl M, Seyfang L, et al. Multidomain Lifestyle Interventions for the Prevention of Cognitive Decline After Ischemic Stroke: Randomized Trial. Stroke. 2015

There is a strong relationship between stroke and dementia. In addition to motor impairments, stroke also leads to cognitive impairment in majority of stroke patients. 30% of such patients deteriorate in a delayed fashion 3-15 months following infarct. Therefore, intervening prior to this deterioration is extremely important in order to decrease risk and progression to dementia. Modifiable vascular risk factors are also linked with an increased risk for cognitive impairment. Therefore, risk factor modification can potentially decrease risk of cognitive decline.


In this study, the authors evaluate whether a 24-month intensive multi-domain intervention can prevent post-stroke cognitive decline compared to standard care. Patients with an ischemic stroke within 3 months were randomly assigned to either group. The intervention consisted of intensive management and motivation for compliance with clinical therapy, blood pressure, lipid and glycemic control, healthy diet, regular physical activity and cognitive training. Cognition was assessed at baseline and 1 and 2 years within the following domains: executive function, working memory, general memory, processing speed and visual spatial ability.

Ultimately, data from 159 patients were obtained (76 intervention and 83 control). At 24 months, 8 patients in the intervention group had cognitive decline compared to 10 in the control group. During the 24 months, participants in the intervention and control group showed no improvement on the Alzheimer’s Disease Assessment Scale-cognitive subscale.

This study did not show a benefit for intensive intervention. This could be due to the relatively low number of patients and thus, the study could have been underpowered to detect an effect. Since dementia is a slowly developing disease, a follow-up period of 24 months may have been too short to capture a difference. Although common for all clinical trials, drop-outs were more frequent in the intervention group in the first year. This, perhaps, suggests the impracticality of intensive intervention due to declining compliance. Furthermore, this type of intervention requires a well-organized medical community with numerous resources. This can be economically unfeasible for many communities.

By |October 13th, 2015|prevention|0 Comments

Standard-dose NOACs preferred to Vitamin K Antagonists in Asian Patients with AFib

Ilana Spokoyny, MD

Wang KL, Lip GYH, Lin SJ, and Chiang CE. Non–Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Asian Patients With Nonvalvular Atrial Fibrillation: Meta-Analysis. Stroke. 2015
 

For Asian patients with atrial fibrillation, there has been hesitation to treating with Vitamin K antagonists due to increased rates of intracranial hemorrhage in Asians. NOACs may represent a safer alternative, but this has not been studied on a large scale in Asian patients until now. The authors performed a meta-analysis using data from recent clinical trials, to assess for differences in safety and efficacy of NOACs in Asian patients. Trials were included if they had more than 500 patients, followed for at least a year, and reported long term efficacy and safety in Asian patients. On literature review, 78 studies were identified but only 5 were included (RE-LY, ROCKET AF, J-ROCKET-AF, ARISTOTLE, ENGAGE AF-TIMI 48.) 8,928 Asian patients (5250 NOAC, 3678 VKA) and 64,033 Non-Asians (37800 NOAC, 26233 VKA) were included. The NOACs included were dabigatran, rivaroxaban, apixaban, and edoxaban. Two separate meta-analyses were performed to compare low- and high-dose NOACs to VKAs. 

Standard Dose NOACs
Efficacy
NOAC vs VKA
Better in Asians? (p-interaction)
stroke or systemic embolism               
better in NOAC
better in Asians
(p int 0.045)       
ischemic stroke                
same in NOAC vs VKA
MI
same in NOAC vs VKA
All-cause mortality                         
better in NOAC
same effect in both groups
Safety
NOAC vs VKA
Better in Asians? (p-interaction)
major bleeding                                
better in NOAC
better in Asians
(p int 0.004)
ICH                                                        
better in NOAC
slightly better in Asians
(p int 0.059)
hemorrhagic stroke                       
better in NOAC
better in Asians
(p int 0.046)
GI bleeding                                        
Mixed picture
less in Asians on NOAC vs VKA – OR 0.79
more in non-Asians on NOAC vs VKA – OR 1.44

Low dose NOACs
Efficacy
NOAC vs VKA
Better in Asians? (p-interaction)
stroke or systemic embolism
same in NOAC vs VKA
ischemic stroke
same in NOAC vs VKA
MI                                                                                         
Mixed picture
same in Asians on NOAC vs VKA
more events in non-Asians on NOAC than VKA (OR 1.28, p=0.01)
All-cause mortality
Better in NOACs
significant reduction in non-Asians, trend for reduction in Asians
Safety
NOAC vs VKA
Better in Asians? (p-interaction)
Major Bleeding
better in NOAC
same in Asians vs non-Asians
Hemorrhagic stroke
better in NOAC
same in Asians vs non-Asians
ICH        
better in NOAC
same in Asians vs non-Asians
GI bleeding        
Trend toward better in NOAC
same in Asians vs non-Asians

One of the limitations addressed by the authors is that they could not determine the actual ethnicity of patients, just their country of residence. Three sensitivity analyses were performed to mitigate these factors, with largely the same results.

A common criticism of standard dose NOACs is their increased risk of GI bleeding – this was only shown to be significant in non-Asians.

So, what explains the differences between Asian and non-Asian patients? We still don’t know. There are likely multiple factors which affect a patient’s or group’s sensitivity to NOACs versus VKAs. The authors note that there may be different genetic polymorphisms in VKA metabolism accounting for higher hemorrhagic stroke in Asians treated with VKAs, with a lower rate by comparison in Asians treated with NOACs. Additional factors in Asians which may contribute to higher hemorrhagic stroke rates with VKAs include: lower body weight and lower creatinine clearance. Other variables identified in Asian patients which are less clearly linked are less prior VKA use (likely due to perception of higher risk of bleed), lower rates of prior MI, less common concomitant use of GI ppx, higher rates of renal impairment, higher rates of prior stroke and non-paroxysmal AFib, and more antiplatelet use.

Overall, the advent of NOACs was a game changer. They provide an easier-to-monitor alternative to Vitamin K Antagonists. This meta-analysis shows that standard dose NOACs are preferred in Asian patients, with regard to both safety and efficacy outcomes. Lower dose NOACs may be an effective and safe alternative in Asian patients with an especially high risk of bleeding, but do not have better efficacy than VKAs. This study can reassure providers in Asian countries (and probably providers in non-Asian countries treating Asian patients) that there are safe and efficacious drugs for stroke prevention in atrial fibrillation. It is likely that many Asian patients are placed on antiplatelets in lieu of VKAs, due to perceived risk of intracerebral bleed. These patients will benefit from anticoagulation, and now have a good alternative to VKAs.

By |August 20th, 2015|prevention|0 Comments

Vitamins and Stroke Mortality: Will an over the counter supplement reduce risk?

Mark McAllister, MD

Dong JY, Iso H, Kitamura A, Tamakoshi A. Multivitamin Use and Risk of Stroke Mortality: The Japan Collaborative Cohort Study. Stroke. 2015

Many patients seeking to improve their overall health and reduce risk of disease turn to the vitamin store. A plethora of products are available and represent a multibillion dollar industry. Previous investigations are divided in whether vitamins reduce the risk of cardiovascular disease, cancer, or other diseases—including the possibility that vitamin supplementation may actually increase risks. The effects of multivitamins on stroke outcomes are not clear.


The Japan Collaborative Cohort study involves collection of many types of data regarding lifestyle habits and health outcomes. Over 72,000 patients were included in this analysis, looking at the risk of death due to stroke by their self-reported multivitamin use. In the adjusted analysis there was a trend towards lower stroke-related mortality in the multivitamin users, but this did not reach statistical significance. In a subgroup analysis there was a significant reduction in stroke mortality in multivitamin users eating fruits and vegetables fewer than three times a day. This effect was not seen in individuals eating fruits and vegetables three or more times a day.

Should we advise patients to add multivitamins to their daily regimen to reduce their risk of stroke? I think it’s difficult to arrive at that conclusion from this observational study. What is likely best is that we continue to advocate for overall healthy patterns of behavior, including a varied diet rich in fruits and vegetables. Reliance on an easy fix in pill form is unlikely to substitute for lifelong healthy habits.

Antithrombotic Meta-Analysis

Ali Saad, MD

Every few years, a meta-analysis comes along to challenge the practice of the ever-controversial ideal antiplatelet regimen in secondary stroke prevention. This meta-analysis looked at 42,234 patients in 17 trials and echoes the current secondary stroke prevention guidelines from the AHA/ASA. Basically, you should definitely prescribe antiplatelets after a stroke (Class 1, Level A), any of the usual agents will do with no clear superiority of one over the other, and there is no evidence to support long term dual antiplatelet therapy. Cilostazol and dipyridamole + asa as monotherapy did outperform aspirin monotherapy for secondary stroke prevention of any type, but that was only in one trial in each case and the results haven’t been reproduced.


 

It’s worth noting that the AHA/ASA does provide a recommendation for dual antiplatelet under certain circumstances (Class IIb, Level B): ASA + clopidogrel first 21 days after a minor stroke or TIA based on the CHANCE trial. ASA + clopidogrel first 90 days after a minor stroke or TIA if referable to severe stenosis of a large intracranial artery (SAMPPRIS trial). Because it’s not standard of care, it’s up to the provider’s discretion and level of comfort with the evidence provided by these 2 trials. however, everyone seems to agree that long term dual antiplatelet is not indicated and has an increased risk of bleeding. several trials also looked at cilostazol, which may be an option in patients who have a genetic resistance to or don’t respond clinically to clopidogrel.
The advantage of using a meta-analysis is that it shows long-term dual antiplatelet is not a practice that should be instituted for all comers with lacunar stroke. Limitations of this trial, as with any meta-analysis, include not being able to compare individual agents across all endpoints, not having uniform criteria for defining a lacunar stroke, not knowing the status of the patient’s vessels, or compliance with certain meds (namely dipyridamole due to its notoriety for causing headaches). An important limitation is that “long-term” is not uniformly defined; it could be anywhere from weeks to years, and so this data cannot be used to refute the findings of CHANCE or SAMPPRIS.
How does this paper change my practice? It reinforces that there is no indication for long term antiplatelet use for secondary stroke prevention beyond 3 months and reminds me that cilostazol is an option in my armamentarium of antiplatelet drugs. Stay tuned for the results of the POINT study in 2017.

Hold On to your Cap: Examining Plaque Components in Symptomatic Carotid Stenosis

Vikas Pandey, MD

De Rotte A, Truijman M, Van Dijk A, Liem M, Schreuder F, Van Der Kolk A, et al. Plaque Components in Symptomatic Moderately Stenosed Carotid ArteriesRelated to Cerebral Infarcts: The Plaque At RISK Study. Stroke. 2015

The carotid ultrasound is the one part of the stroke workup truly essential due to the established evidence-based guidelines regarding carotid revascularization in symptomatic carotid stenosis. The selection of candidates for carotid revascularization however is currently decided by medical professionals picking a number (i.e. >70%) that they feel is high enough to warrant a procedure for patients with strokes on the ipsilateral side of the carotid stenosis (symptomatic carotid stenosis). A better question to ask is whether the carotid plaque, regardless of degree of stenosis, has characteristics that make it a “dangerous” plaque at risk of rupturing again. The group out of the Netherlands asked this question and decided to assess carotid plaques with 3 Tesla MRI scanners to assess whether particular plaque components (intraplaque hemorrhage (IPH) or thin/ruptured fibrous cap (TRFC)) were associated with the presence of infarcts on MRI.




The group analyzed 101 patients with symptomatic 30-69% carotid artery stenosis who underwent a 3T MRI of the carotid arteries and the brain within 45 days of symptom onset. They used two different readers blinded to the brain MRI results, to analyze the carotid artery MRI and examine them for IPH and TRFC. They found that IPH was present in 40 out of the 101 patient with 55% having infarcts on the side of the carotid plaque however in the patients without IPH, 41% had infarcts on the symptomatic side (p= 0.22). A TRFC was present in 49 out of 86 patients (15 patients could not have fibrous cap assessed), with 45% having infarcts on the side of the symptomatic carotid however this was not significantly different from the 49% in the 37 patients with a thick fibrous cap. The significance did not change when only cortical (instead of both subcortical and cortical) infarcts were taken into account.

Though the data was a bit underwhelming in terms of significance, the study still provides important findings and implications regarding the future of plaque analysis in determining who would be a good candidate for carotid revascularization. Perhaps an imaging method besides MRI may be better suited for identifying plaque components or perhaps the best series for analyzing these components on MRI has not been defined as of yet. Regardless, the thought process demonstrated by the authors is an ideal one that all practitioners should follow rather than simply letting a number dictate treatment.

@DrVikasNeuro
By |January 20th, 2015|prevention|0 Comments

Improving Stroke Education with High School Students

Rizwan Kalani, MD

Matsuzono K, Yokota C, Takekawa H, Okamura T, Miyamatsu N, Nakayama H, et al. Effects of Stroke Education of Junior High School Students on Stroke Knowledgeof Their Parents: Tochigi Project. Stroke. 2015

The Tochigi prefecture (district), with its 2 million inhabitants, has among the highest stroke mortality rates in Japan. In this study, Matsuzono et al evaluated if teaching high school students about stroke (signs/symptoms, appropriate action at onset, risk factors, and the FAST mnemonic) could improve their parents’ knowledge about stroke in a large, high-risk community.


1127 students (13-15 years old) were enrolled along with their parents. Baseline questionnaires assessed knowledge regarding stroke of both the students and their parents. Public health workers then gave students a stroke didactic, showed a brief cartoon, and read a comic to them. This was followed by having the students take the comic home and reviewing it with their parents. Follow-up questionnaires assessing knowledge regarding stroke were then completed.

Results from questionnaires were evaluated from 1125 students and 915 parents/guardians (of which 137 were medical professionals). The number of correct answers increased significantly for all questions in students, except that corresponding to headache as a stroke symptom (60.7% prior and 94.3% after, p<0.001). Similarly, the parents answered questions correctly with significantly increased frequency except recognition of headache and hemisensory loss as acute stroke symptoms and hypertension as a risk factor (83.0% vs 92.7%, p<0.001). 91% of students and 93% of parents understood the FAST mnemonic after being taught.

This study again demonstrates that young adults and children attending school can assist in improving stroke education to high risk populations. It shows that simple, culturally-tailored, population-based approaches to improving stroke outcomes can be effectively implemented. Future work will have to evaluate if such strategies can affect outcomes (improving vascular risk factor screening/control and health-related behaviors), be applied more broadly for public health education and stroke prevention, and be improved to maximize impact.

By |January 5th, 2015|prevention|0 Comments

Should one RESPECT the CLOSURE of a PFO? Nah, a pill will do!

Chirantan Banerjee, MD

Katsanos AH, Spence JD, Bogiatzi C, Parissis J, Giannopoulos S, Frogoudaki A, et al. Recurrent Stroke and Patent Foramen Ovale: A Systematic Review and Meta-Analysis. Stroke. 2014

PFOs have high prevalence in the general population, but have been found more often in patients with cryptogenic stroke, and with larger size and associated atrial septal aneurysm. One of the most controversial topics in the stroke community over several decades has been the issue of patent foramen ovale (PFO) and its association with cryptogenic stroke, as well as medical therapy v/s closure of the atrial septal defect.


In the last 3 years, 3 randomized controlled clinical trials have been published amid a lot of scrutiny and hype. CLOSURE I trial, published in 2012 was first of the three, and compared closure with StarFlex device to medical therapy in cryptogenic stroke patients with PFO, and found that stroke recurrence was low in this population, and there was no benefit of closure over medical therapy.  PC Trial and RESPECT trial, both came out last year, and compared PFO closure with the Amplatzer PFO Occluder (St. Jude Medical) to medical therapy in patients with cryptogenic stroke. There were no significant differences in the primary endpoint (composite of death, nonfatal stroke, TIA, or peripheral embolism) or the individual components of the endpoint in the PC trial. But lower than expected event rates were again seen. In the RESPECT trial, again there was no significant difference in the main, intention-to-treat analysis (composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomization), but prespecified per-protocol and as-treated analyses hinted at significant benefits for PFO closure. Also, secondary analyses suggested benefit in patients with substantial (grade 3) right-to-left shunt and atrial septal aneurysm.

 Thus, the results provided arguments to both advocates and skeptics. All 3 trials were plagued by slow enrollment rates (attributed to substantial off-label use), as well as low event rates. Advocates argue that the follow-up in the trials were not long enough to demonstrate benefit.  


In the current study, Katsanos et al. undertook a meta-analysis of all available prospective studies reporting recurrent stroke/TIA rates in cryptogenic stroke patient with PFO. They used PRISMA guidelines and identified prospective studies by literature search, and as well as obtained additional data from authors of the included studies. Out of potential 21 studies, they excluded studies without controls, those mixing endpoints of medically and surgically treated patients, and those with combined outcome. Appropriate statistical tools were used, including the mixed effects model to combine data, and Cochrane Q and I2 statistic for heterogeneity. Shunt size was dichotomized as small or moderate – large. 

They found that medically treated cryptogenic stroke patients with PFO did not have a higher risk of recurrent stroke (RR=0.85; 95% CI= 0.59-1.22; p=0.37) or recurrent stroke/TIA (RR=1.18; 95% CI, 0.78-1.79; p=0.43). Also, size of PFO was not associated with the risk of recurrent stroke/TIA. Despite the usual limitations of meta-analyses like selection bias, publication bias, attrition bias etc., these findings add significant weight to the growing argument against closure of PFO in cryptogenic stroke patients, which is also the current AHA guideline. 

Another meta-analysis by Spencer et al. published in the BMJ earlier this year had also concluded that there was insufficient support for closure as compared to medical therapy, even when the analysis is restricted to ‘per-protocol’ patients or patients with concomitant atrial septal aneurysm. The lack of association with PFO size in this study corroborates with findings from the ROPE database. 

Currently enrolling industry sponsored REDUCE randomized trial will evaluate closure by the Gore septal occluder v/s medical therapy. But, given the findings of the above studies, I am not sure it will tell us anything that we do not expect already!

By |October 30th, 2014|prevention|0 Comments

Guideline-Directed LDL Management in Stroke

A. Kaleel, MD, MSc

Saposnik G, Fonarow GC, Pan W, Liang L, Hernandez AF, Schwamm LH, et al. Guideline-Directed Low-Density Lipoprotein Management in High-Risk Patients With Ischemic Stroke: Findings From Get With The Guidelines-Stroke 2003 to 2012. Stroke. 2014

As secondary prevention management guidelines have proven effective at reducing the risk of recurrent vascular events, there remains concern that there is lack of adherence to these guidelines. This study sought to assess the “real world” success of achieving NCEP-ATP III LDL guideline goals in high risk stroke patients with prior cardiovascular or cerebrovascular disease. In particular, this observational study focused on LDL levels at the new index event of TIA or stroke in the following categories: patients with pre-existing TIA/stroke, pre-existing CAD, pre-existing concomitant CVD and CAD, and no pre-existing CAD/CVD. 




Among the 913,436 patients evaluated from the Get With The Guidelines (GWTG)-Stroke Program between April 2003 to September 2012 within the 1246 participating institutions, 21.3% had a pre-existing TIA/stroke, 16.3% had a pre-existing CAD, 9.7% had concomitant CAD and CVD, and 52.7% had no known documented history of CVD or CAD.

It was discovered at the index event that the mean LDL was 100.9 in those with pre-existing CVD, 95.1 in those with pre-existing CAD, 93.5 in those with both CAD and CVD, and 111 in those without pre-existing CAD/CVD. To put this into perspective, only 21.4% of patients with pre-existing TIA/stroke with a new stroke achieved an LDL <70 and this was also true for only 28.5% of pre-existing CAD patients. 

Overall, only 68% of stroke patients were at their pre-admission NCEP III guideline-recommended LDL target and among those who presented with recurrent stroke, more than 45% had LDL >100.


Encouragingly, the data revealed a temporal shift in LDL management, with improved LDL control over time. This study particularly highlights the disparity between the guidelines and actual realization among these patients. In multivariable analysis, older age, male, white race, lack of major vascular risk factors, prior use of cholesterol-lowering therapy, and care provided in larger hospitals were associated with meeting LDL targets on admission testing.

By |October 29th, 2014|prevention|0 Comments

Triglyceride/HDL ratio as a maker for recurrent stroke risk

Duy Le, MD


Park JH, Lee J, and Ovbiagele B. Nontraditional Serum Lipid Variables and Recurrent Stroke Risk. Stroke. 2014


Park et al evaluate whether markers outside of LDL alone have any predictive value for secondary prevention of stroke. They evaluate ratios of TG/HDL, TC/HDL, LDL/HDL. Data was reviewed from the Vitamin Intervention for stroke Prevention (VISP) trial. The VISP trial was a multicenter, double blinded, randomized control trial performed in 2004 at centers across the US, Canada and Scotland which enrolled 3680 patients to determine whether high doses of multivitamin given to lower homocysteine levels would reduce the risk of recurrent stroke and major vascular events in non-cardioembolic ischemic stroke. Primary results from this study showed that folate supplementation for elevated homocysteine levels did not change outcomes in terms of recurrent stroke. In this study, serum lipid levels were obtained after an overnight 12 hour fast and at 6,12 and 24 month visits. Park et al tap into this data set. Patient’s data were pulled from their last follow up visit which was defined by the last documented study encounter that preceded either a vascular outcome event or end of trial. Primary outcome was ischemic stroke. Secondary outcome was a composite of stroke, CHD, MI or vascular death. 



Each lipid variable was divided into quintiles. A hazard ratio for vascular events by increasing strata was calculated. In the end, when comparing the top quintile to the bottom quintile, the only category which had a p value of significance for both the primary and secondary outcome was the triglyceride/HDL ratio. 

Taken altogether, there is suggestion that elevated TG/HDL ratios may be of prognostic value for identifying subjects at risk of a secondary stroke. Prior populations studies have shown no relation between TG/HDL ratios and an increased risk of stroke. However the population evaluated from that study was a mixed patient population. From a secondary standpoint however, TG/HDL may have significance.  If this finding is true, then there may be a role of adding a fibrate on to standard statin therapy to decrease the risk of a secondary stroke. Evaluation of this theory would include a double blinded randomized controlled trial with statin vs statin + fibrate and evaluating stroke as a primary outcome and TG/HDL ratios as a secondary outcome.
By |October 20th, 2014|prevention|0 Comments