cardiovascular-agents and Stroke

Mammalian models including non-human primates, pigs and rodents have been used extensively to study the mechanisms of cardiovascular disease. However, there is an increasing desire for alternative model systems that provide excellent scientific value while replacing or reducing the use of mammals. Here, we review the use of zebrafish, Danio rerio, to study cardiovascular development and disease. The anatomy and physiology of zebrafish and mammalian cardiovascular systems are compared, and we describe the use of zebrafish models in studying the mechanisms of cardiac (e.g. congenital heart defects, cardiomyopathy, conduction disorders and regeneration) and vascular (endothelial dysfunction and atherosclerosis, lipid metabolism, vascular ageing, neurovascular physiology and stroke) pathologies. We also review the use of zebrafish for studying pharmacological responses to cardiovascular drugs and describe several features of zebrafish that make them a compelling model for in vivo screening of compounds for the treatment cardiovascular disease. LINKED ARTICLES: This article is part of a themed issue on Preclinical Models for Cardiovascular disease research (BJP 75th Anniversary). To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.5/issuetoc.

Topics: Aging; Animals; Cardiovascular Agents; Cardiovascular Diseases; Humans; Mammals; Stroke; Swine; Zebrafish

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Topics: Animals; Aortic Aneurysm; Cardiovascular Agents; Diabetes Mellitus; Humans; Hypoglycemic Agents; Peripheral Arterial Disease; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stroke; Treatment Outcome

Since the outbreak of coronavirus disease 2019 (COVID-19) in 2019, it is gaining worldwide attention at the moment. Apart from respiratory manifestations, neurological dysfunction in COVID-19 patients, especially the occurrence of cerebrovascular diseases (CVD), has been intensively investigated. In this review, the effects of COVID-19 infection on CVD were summarized as follows: (I) angiotensin-converting enzyme 2 (ACE2) may be involved in the attack on vascular endothelial cells by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), leading to endothelial damage and increased subintimal inflammation, which are followed by hemorrhage or thrombosis; (II) SARS-CoV-2 could alter the expression/activity of ACE2, consequently resulting in the disruption of renin-angiotensin system which is associated with the occurrence and progression of atherosclerosis; (III) upregulation of neutrophil extracellular traps has been detected in COVID-19 patients, which is closely associated with immunothrombosis; (IV) the inflammatory cascade induced by SARS-CoV-2 often leads to hypercoagulability and promotes the formation and progress of atherosclerosis; (V) antiphospholipid antibodies are also detected in plasma of some severe cases, which aggravate the thrombosis through the formation of immune complexes; (VI) hyperglycemia in COVID-19 patients may trigger CVD by increasing oxidative stress and blood viscosity; (VII) the COVID-19 outbreak is a global emergency and causes psychological stress, which could be a potential risk factor of CVD as coagulation, and fibrinolysis may be affected. In this review, we aimed to further our understanding of CVD-associated COVID-19 infection, which could improve the therapeutic outcomes of patients. Personalized treatments should be offered to COVID-19 patients at greater risk for stroke in future clinical practice.

Topics: Anticoagulants; Antiviral Agents; Atherosclerosis; Cardiovascular Agents; COVID-19; COVID-19 Drug Treatment; Disseminated Intravascular Coagulation; Extracellular Traps; Hemorrhage; Humans; Hyperglycemia; Inflammation; Renin-Angiotensin System; SARS-CoV-2; Stroke; Thrombosis

Dietary flavonoids have shown potential in the prevention of noncommunicable diseases. The aim of the present study is to conduct a dose-response meta-analysis on the association between dietary intake of total, subclasses and individual flavonoids and risk of cardiovascular disease (CVD).. Electronic databases are searched. A total of 39 prospective cohort studies are included, comprising 1 501 645 individuals and a total of 33 637 cases of CVD, 23 664 of coronary heart disease (CHD), and 11 860 of stroke. Increasing dietary intake of total flavonoids is linearly associated with a lower risk of CVD. Among the main classes of flavonoids, increasing intake of anthocyanins and flavan-3-ols is inversely associated with risk of CVD, while flavonols and flavones with CHD. Only increasing flavanones showed a linear inverse association with stroke risk. Catechins showed a favorable effect toward all cardiovascular outcomes. Among individual compounds, intake of quercetin and kaempferol is linearly associated with lower risk of CHD and CVD, respectively. However, higher intake of all the aforementioned compounds is associated, with a various extent, with a lower risk of CVD when considering comparison of extreme categories of consumption.. The results of this study provide evidence of potential cardiovascular benefits of a flavonoid-rich diet.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Diet; Dose-Response Relationship, Drug; Flavonoids; Humans; Risk Factors; Stroke

Cyclin-dependent kinases (CDKs) are involved in many crucial processes, such as cell cycle and transcription, as well as communication, metabolism, and apoptosis. The kinases are organized in a pathway to ensure that, during cell division, each cell accurately replicates its DNA, and ensure its segregation equally between the two daughter cells. Deregulation of any of the stages of the cell cycle or transcription leads to apoptosis but, if uncorrected, can result in a series of diseases, such as cancer, neurodegenerative diseases (Alzheimer's or Parkinson's disease), and stroke. This review presents the current state of knowledge about the characteristics of cyclin-dependent kinases as potential pharmacological targets.

Topics: Alzheimer Disease; Animals; Antineoplastic Agents; Apoptosis; Cardiomegaly; Cardiovascular Agents; Cell Cycle; Cyclin-Dependent Kinases; Cyclins; Gene Expression Regulation; Humans; Neoplasms; Neuroprotective Agents; Parkinson Disease; Protein Kinase Inhibitors; Saccharomyces cerevisiae; Stroke

Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal.. We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017.. Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention.. Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Combined Modality Therapy; Counseling; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Patient Selection; Risk Assessment; Risk Factors; Risk Reduction Behavior; Stents; Stroke; Treatment Outcome

The polypill, referring to a variety of combinations of low-cost cardiovascular and stroke preventive medications combined in a single tablet, has been evaluated as a population-based approach for cardiovascular disease prevention in several trials. This review summarizes the scope of the problem, main trial results, and their potential applicability to the US population.. Initial trials demonstrated the efficacy of the polypill approach. The most recent, the PolyIran study, showed the effectiveness of one form of a polypill for cardiovascular disease prevention, high medication adherence, and low adverse event rates. None of published polypill trials focused on stroke as the primary outcome and most were conducted in developing countries, limiting generalization to the US population. A US-based randomized trial with stroke as the primary outcome is needed to assess the usefulness of this approach for stroke prevention in the USA.

Topics: Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Drug Combinations; Humans; Medication Adherence; Stroke

Stroke is a leading cause of adult mortality and disability worldwide. Extracranial atherosclerotic disease (ECAD), primarily, carotid artery stenosis, accounts for approximately 18%-25% of ischaemic stroke. Recent advances in neuroimaging, medical therapy and interventional management have led to A significant reduction of stroke from carotid artery stenosis. The current treatment of ECAD includes optimal medical therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). The selection of treatments depends on symptomatic status, severity of stenosis, individual factors, efficacy and risk of complications. The aim of this paper is to review current evidence and guidelines on the management of carotid artery stenosis, including the comparison of medical and interventional therapy (CAS and CEA), as well as future directions.

Topics: Brain Ischemia; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Endovascular Procedures; Humans; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stents; Stroke; Treatment Outcome

This meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT).. The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized.. Overall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312-0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810-6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548-14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668-50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361-0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223-1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found.. CEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.

Topics: Aged; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Endovascular Procedures; Female; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome

Cryptogenic strokes account for about 25% to 40% of total ischemic strokes, and 1 of the 3 of these have a patent foramen ovale (PFO). A meta-analysis concerning the effectiveness and safety of PFO closure in cryptogenic strokes or transient ischemic attacks (TIAs) was performed. We systematically searched Medline, Embase, and the Cochrane Library through April 2018. Eligible studies were randomized clinical trials. Primary and secondary end points were, respectively, stroke or TIA and stroke recurrences. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for all end points using fixed- and random-effects meta-analyses. Data were included from 6 trials involving 3560 patients. In the pooled analysis, PFO closure was superior to medical treatment for both primary (RR: 0.39; 95% CI: 0.18-0.82; P < .02) and secondary end points (RR: 0.58; 95% CI: 0.44-0.76; P < .001). Transcatheter closure significantly increased the risk of new-onset atrial fibrillation (AF; RR: 5.74; P < .001). Percutaneous closure is superior to medical treatment in reducing stroke and TIA recurrence, even if with a significant risk increasing for new-onset AF. These findings suggest that transcatheter closure is indicated in patients with cryptogenic strokes and large PFO.

Topics: Adult; Age Factors; Atrial Fibrillation; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Sex Factors; Stroke; Time Factors; Treatment Outcome

The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone.. PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance.. A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33-0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52-1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33-1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06-11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55-1.57, p = 0.78).. The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

Topics: Adolescent; Adult; Cardiac Catheterization; Cardiovascular Agents; Combined Modality Therapy; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome; Young Adult

Cardiovascular disease (CVD), principally myocardial infarction (MI) and stroke, is the leading clinical and public health problem in the United States and is rapidly becoming so worldwide. Their primary prevention is promising, in theory, but difficult to achieve in practice. The principal modalities that have demonstrated efficacy include therapeutic lifestyle changes (TLCs) and adjunctive drug therapies under the guidance of the health-care provider and tailored to the individual patient. The prevention and treatment of the pandemic of overweight and obesity and lack of regular physical activity, both of which are alarmingly common in the United States, prevention and treatment of hypertension, avoidance and cessation of cigarette smoking, adoption and maintenance of a healthy diet, and avoidance of heavy alcohol consumption all have proven benefits in decreasing the risks of a first MI and stroke as well as other clinical manifestations of CVD. Although adoption of TLCs would avoid the need for adjunctive drug therapies in many primary prevention subjects, this strategy is difficult to achieve or maintain for most and may be insufficient for many, especially those at high risk with metabolic syndrome. The criteria for metabolic syndrome, affecting over 40% of the adult population older than 40 in the United States, include overweight or obesity, dyslipidemia, hypertension, and insulin resistance, a precursor of diabetes. The adjunctive therapies of proven benefit in the primary prevention of MI and stroke include statins, blood pressure medications, aspirin, and drugs to treat insulin resistance and hyperglycemia. Fortunately, even for patients who prefer prescription of pills to proscription of harmful lifestyles, these drug therapies still have net benefits. The adoption and maintenance of TLCs and adjunctive drug therapies into clinical practice will reduce both the incidence of and mortality from a first MI and stroke as well as other major clinical manifestations of CVD.

Topics: Cardiovascular Agents; Healthy Lifestyle; Humans; Incidence; Myocardial Infarction; Primary Prevention; Protective Factors; Risk Assessment; Risk Factors; Risk Reduction Behavior; Stroke; Treatment Outcome

New-onset atrial fibrillation (NOAF) is common and associated with increased morbidity and mortality. However, its clinical importance and management in critically ill patients are not well described. The aim of this scoping review is to assess the epidemiology and management strategies of NOAF during critical illness.. The review was conducted in accordance with the PRISMA extension for scoping reviews. We searched PubMed, EMBASE and the Cochrane Library for studies assessing the incidence, outcome and management strategies of NOAF in adult critically ill patients. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.. A total of 99 studies were included, of which 79 were observational and 20 were interventional. The incidence of NOAF varied from 1.7% to 43.9% with considerable inter-population variation (very low quality of evidence). Commonly identified risk factors for NOAF included higher age, cardiovascular comorbidities and sepsis. The occurrence of NOAF was associated with adverse outcomes, including stroke, prolonged length of stay and mortality (very low quality of evidence). We found limited data on the optimal management strategy with no evidence for firm benefit or harm for any intervention (very low/low quality of evidence).. The definition and incidence of NOAF in critically ill patients varied considerably and many risk factors were identified. NOAF seemed to be associated with adverse outcomes, but data were very limited and current management strategies are not evidence-based.

Topics: Age Factors; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Critical Illness; Electrocardiography; Hematologic Tests; Hospitalization; Humans; Incidence; Length of Stay; Risk Factors; Sepsis; Severity of Illness Index; Sex Factors; Stroke

This review summarizes the potential for polypill therapies for stroke prevention. While a number of studies applying different approaches regarding polypill have been performed, none of them has had a focus on stroke as the main outcome. A combination pill containing drugs such as statins, diuretics, and other antihypertensives is currently available in various formats. Estimates focusing mostly on primary prevention show that using such a combination drug a reduction in the 5-year stroke incidence by 50% can be achieved - especially in low- and middle-income countries with a high prevalence of risk factors even among people at young ages. A combination of a large supporting population-wide program with a registry-based quality control is the most likely perspective and can be achieved within a reasonable time frame and potentially have significant influence in young stroke populations.

Topics: Cardiovascular Agents; Drug Combinations; Humans; Medication Adherence; Polypharmacy; Population Groups; Primary Prevention; Randomized Controlled Trials as Topic; Risk Factors; Stroke

Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cryptogenic stroke. However, the comparative efficacy and safety of percutaneous closure and medical therapy in patients with cryptogenic stroke and PFO remain unclear.. Randomized controlled trials (RCTs) and comparative observational studies that compared PFO closure against medical therapy, each with a minimal of 20 patients in the closure arm and 1-year follow-up were included.. We analyzed 6961 patients from 20 studies (5 RCTs and 15 observational studies) with a median follow-up of 3.1 years. Moderate-quality evidence showed that PFO closure was associated with a significantly lower incidence of the composite outcome of ischemic stroke, transient ischemic attack (TIA), or all-cause death (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.38 to 0.85; P = 0.006), mainly driven by lower incidence of stroke (OR: 0.39; 95% CI: 0.24 to 0.63; P < 0.001). The numbers needed to treat were 43 and 39 for the composite outcome and recurrent ischemic stroke respectively. PFO closure increased the risks for atrial fibrillation or atrial flutter (OR: 5.74; 95% CI: 3.08 to 10.70; P < 0.001; high-quality evidence) and pulmonary embolism (OR: 3.03; 95% CI: 1.06 to 8.63; P = 0.038; moderate-quality evidence), with the numbers needed to harm being 30 and 143 respectively. The risks for TIA, all-cause death, and major bleeding were not statistically different. Analyses limited to RCTs showed similar findings, as did a series of other subgroup analyses.. In conclusion, PFO closure reduced the incidences of stroke and the composite outcome of ischemic stroke, TIA, or all-cause death, but increased risks for atrial fibrillation or atrial flutter and pulmonary embolism compared with medical therapy.

Topics: Adult; Atrial Fibrillation; Atrial Flutter; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Incidence; Ischemic Attack, Transient; Male; Middle Aged; Observational Studies as Topic; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Factors; Stroke; Time Factors; Treatment Outcome

Patent foramen ovale (PFO) with atrial septal aneurysm is suggested as an important potential source for cryptogenic strokes. Percutaneous PFO closure to reduce the recurrence of stroke compared to medical therapy has been intensely debated. The aim of this study is to assess whether PFO closure in patients with cryptogenic stroke is safe and effective compared with medical therapy.. A search of PubMed, Medline, and Cochrane Central Register from January 2000 through September 2017 for randomized controlled trails (RCT), which compared PFO closure to medical therapy in patients with cryptogenic stroke was conducted. We used the items "PFO or patent foramen ovale", "paradoxical embolism", "PFO closure" and "stroke". Data were pooled for the primary outcome measure using the random-effects model as pooled rate ratio (RR). The primary outcome was reduction in recurrent strokes.. Among 282 studies, 5 were selected. Our analysis included 3,440 patients (mean age 45 years, 55% men, mean follow-up 2.9 years), 1,829 in the PFO closure group and 1,611 in the medical therapy group. The I2 heterogeneity test was found to be 48%. A random effects model combining the results of the included studies demonstrated a statistically significant risk reduction in risk of recurrent stroke in the PFO closure group when compared with medical therapy (RR 0.42; 95% CI 0.20-0.91, p = 0.03).. Pooled data from 5 large RCTs showed that PFO closure in patients with cryptogenic stroke is safe and effective intervention for prevention of stroke recurrence compared with medical therapy.

Topics: Adult; Cardiac Catheterization; Cardiovascular Agents; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome

We performed a systematic review and meta-analysis of randomized controlled trials to assess the effect of closure of a patent foramen ovale (PFO) compared with medical therapy for the prevention of stroke in patients with prior cryptogenic stroke.. The role of PFO closure in reducing risk of stroke in patients with prior cryptogenic stroke has been controversial.. We searched PubMed, Embase, CINAHL, and CENTRAL for randomized trials investigating PFO closure versus medical therapy. We assessed trial bias and the quality of evidence for main outcomes was rated using GRADE. The primary outcome of interest was the occurrence of stroke. Estimates of effect were pooled with a random-effects model. This study is registered with PROSPERO (CRD42017081579).. PFO closure reduced risk of stroke compared with medical therapy. PFO closure is a therapeutic option that should be offered to adults with cryptogenic stroke.

Topics: Adolescent; Adult; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Male; Middle Aged; Prosthesis Design; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Septal Occluder Device; Stroke; Time Factors; Treatment Outcome; Young Adult

The optimal strategy of secondary stroke prevention in patients with patent foramen ovale (PFO) is controversial. This study was performed to evaluate the efficacy and safety of the device closure (DC) versus the medical therapy (MT) in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.. Randomized controlled trials with active and control groups receiving the DC plus MT and MT alone in patients with history of cryptogenic stroke/TIA and diagnosis of PFO were systematically searched. The main efficacy outcome was stroke recurrence. Subgroup-analyses were performed according to age, shunt size, and presence of atrial septal aneurysm (ASA). Safety endpoints included any serious adverse event (SAE), atrial fibrillation (AF), and major bleeding complications. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were estimated. Five trials were included, involving 3,440 participants (DC = 1,829, MT = 1,611). There was a protective effect of closure in the risk of recurrent stroke (RR 0.43 [0.21-0.90]; p = 0.024; HR = 0.39 [0.19-0.83]; p = 0.014). The benefit of PFO closure was significant in patients with PFO associated with substantial right-to-left shunt or ASA. There were no differences in the risks of SAEs and major bleedings between the groups. The rate of new-onset AF was higher in the DC than in the MT arm (RR 4.46 [2.35-8.41]; p < 0.001). Successful device implantation and effective PFO closure were achieved in 96 and 91% of the patients respectively. Key Messages: In selected adult patients with PFO and history of cryptogenic stroke, the DC plus MT is more effective to prevent stroke recurrence and is associated with an increased risk of new-onset AF compared to the MT alone.

Topics: Adult; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Male; Middle Aged; Protective Factors; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome

To examine long-term clinical outcomes with transcatheter patent foramen ovale (PFO) closure versus medical therapy alone in patients with cryptogenic stroke.. A long-standing debate regarding the optimal approach for the management of patients with PFO after a cryptogenic stroke exists.. An electronic search was performed for randomized clinical trials (RCTs) reporting clinical outcomes with PFO closure vs. medical therapy alone after stroke. Random effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was recurrence of stroke. Other outcomes included transient ischemic attack (TIA), new-onset atrial fibrillation/flutter (AF/AFL), major bleeding, serious adverse events, and device-related complications. All-cause mortality was also examined.. Transcatheter PFO closure reduces the recurrence of stroke compared with medical therapy alone, with no significant safety concerns. Close follow-up of patients after PFO closure is recommended to detect new-onset atrial arrhythmias.

Topics: Adult; Cardiac Catheterization; Cardiovascular Agents; Female; Foramen Ovale, Patent; Humans; Male; Middle Aged; Prosthesis Design; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Septal Occluder Device; Stroke; Time Factors; Treatment Outcome

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Randomized Controlled Trials as Topic; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Whether revascularisation is superior to medical therapy in older populations presenting with non-ST-elevation acute coronary syndromes (NSTEACS) remains contentious, with inconclusive evidence from randomised trials. We aimed to compare routine invasive therapy with initial medical management in the elderly presenting with NSTEACS.. MEDLINE, EMBASE and Cochrane Controlled Trial Register were searched for studies comparing routine invasive therapy with initial medical management in patients ≥75 years old presenting with NSTEACS. Endpoints included long-term mortality, myocardial infarction (MI), revascularisation, rehospitalisation, stroke and major bleeding reported as ORs.. Four randomised trials and three observational studies met inclusion criteria, enrolling a total of 20 540 patients followed up from 6 months to 5 years. Routine invasive therapy reduced mortality (OR 0.67, CI 0.61 to 0.74), MI (OR 0.56, CI 0.45 to 0.70) and stroke (OR 0.53, CI 0.30 to 0.95). Analyses restricted to randomised controlled trials (RCTs) confirmed a reduction in MI (OR 0.51, CI 0.40 to 0.66), revascularisation (OR 0.27, CI 0.13 to 0.56) and a trend to reduced mortality (OR 0.84, CI 0.66 to 1.06) at the expense of major bleeding (OR 2.19, CI 1.12 to 4.28). Differences in major bleeding were unapparent in more recent studies.. Routine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.

Topics: Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Bypass; Female; Hemorrhage; Humans; Male; Non-ST Elevated Myocardial Infarction; Odds Ratio; Patient Readmission; Percutaneous Coronary Intervention; Recurrence; Risk Factors; Stroke; Time Factors; Treatment Outcome

Contemporary medical therapy consists of identification and treatment of all patient-modifiable vascular risk factors. Specific atherosclerotic disease therapies are designed to reduce the risk of thrombosis, and the disease progression in order to reduce the risk of future cardiovascular events. Contemporary medical management emphasizes the need to support the patient in achieving lifestyle modifications and to adjust medication to achieve individualized target values for specific quantifiable risk factors. Antiplatelet therapy in the form of aspirin or clopidogrel is routinely used for the prevention of ischemic stroke in patients who have had a transient ischemic attack or stroke. There is evidence from a recent trial that the use of combination antiplatelet therapy with aspirin and clopidogrel started within 24 hours of minor stroke or transient ischemic attack reduces the risk of recurrent stroke compared to the use of aspirin alone, and therefore we use aspirin plus clopidogrel in recently symptomatic patients with carotid stenosis pending carotid revascularization. Anticoagulation with heparins or vitamin K antagonist is not recommended except in patients at risk for cardio-embolic events. Lowering blood pressure to target levels has been shown to slow down the progression of carotid artery stenosis and reduces the intima-media thickness of the carotid plaque, while lowering lipid levels with statins has become an essential element in the medical therapy of carotid artery stenosis. Diabetes management should be optimized. Lifestyle choices, including tobacco smoking, physical inactivity, unhealthy diet, obesity, and excessive alcohol intake, are all important modifiable vascular risk factors. The combination of dietary modification, physical exercise, and use of aspirin, a statin, and an antihypertensive agent can be expected to give a cumulative relative stroke risk reduction of 80%. The evidence suggests that intensive medical therapy is so effective that carotid revascularization may no longer be necessary in many of the patients in whom carotid surgery or stenting is currently performed. Two large ongoing trials are therefore comparing the risks and benefits of carotid revascularization versus intensive medical therapy alone.

Topics: Cardiovascular Agents; Carotid Artery Diseases; Diet, Healthy; Evidence-Based Medicine; Exercise; Humans; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Risk Factors; Risk Reduction Behavior; Stroke; Treatment Outcome

Stroke is the second leading cause of mortality and morbidity worldwide. Early intervention is of great importance in reducing disease burden. Since the conventional risk factors cannot fully account for the pathogenesis of stroke, it is extremely important to detect useful biomarkers of the vascular disorder for appropriate intervention. Arterial stiffness, a newly recognised reliable feature of arterial structure and function, is demonstrated to be associated with stroke onset and serve as an independent predictor of stroke incidence and poststroke functional outcomes. In this review article, different measurements of arterial stiffness, especially pressure wave velocity, were discussed. We explained the association between arterial stiffness and stroke occurrence by discussing the secondary haemodynamic changes. We reviewed clinical data that support the prediction role of arterial stiffness on stroke. Despite the lack of long-term randomised double-blind controlled therapeutic trials, it is high potential to reduce stroke prevalence through a significant reduction of arterial stiffness (which is called de-stiffening therapy). Pharmacological interventions or lifestyle modification that can influence blood pressure, arterial function or structure in either the short or long term are promising de-stiffening therapies. Here, we summarised different de-stiffening strategies including antihypertension drugs, antihyperlipidaemic agents, chemicals that target arterial remodelling and exercise training. Large and well-designed clinical trials on de-stiffening strategy are needed to testify the prevention effect for stroke. Novel techniques such as modern microscopic imaging and reliable animal models would facilitate the mechanistic analyses in pathophysiology, pharmacology and therapeutics.

Topics: Animals; Cardiovascular Agents; Exercise Therapy; Hemodynamics; Humans; Pulse Wave Analysis; Recovery of Function; Risk Reduction Behavior; Stroke; Treatment Outcome; Vascular Stiffness

Avoiding medications in which the risks outweigh the benefits in the elderly patient is a challenge for physicians, and different criteria to identify inappropriate prescription (IP) exist to aid prescribers. Definition of IP indicators in the Italian geriatric population affected by cardiovascular disease and chronic comorbidities could be extremely useful for prescribers and could offer advantages from a public health perspective. The purpose of the present study was to identify IP indicators by means of a systematic literature review coupled with consensus criteria. A systematic search of PubMed, EMBASE, and CENTRAL databases was conducted, with the search structured around four themes and combining each with the Boolean operator "and". The first regarded "prescriptions", the second "adverse events", the third "cardiovascular conditions", and the last was planned to identify studies on "older people". Two investigators independently reviewed titles, abstracts, full texts, and selected articles addressing IP in the elderly affected by cardiovascular condition using the following inclusion criteria: studies on people aged ≥65 years; studies on patients with no restriction on age but with data on subjects aged ≥65 years; and observational effectiveness studies. The database searches produced 5,742 citations. After removing duplicates, titles and abstracts of 3,880 records were reviewed, and 374 full texts were retrieved that met inclusion criteria. Thus, 49 studies reporting 32 potential IP indicators were included in the study. IP indicators regarded mainly drug-drug interactions, cardio- and cerebrovascular risk, bleeding risk, and gastrointestinal risk; among them, only 19 included at least one study that showed significant results, triggering a potential warning for a specific drug or class of drugs in a specific context. This systematic review demonstrates that both cardiovascular and non-cardiovascular drugs increase the risk of adverse drug reactions in older adults with cardiovascular diseases.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Drug Interactions; Hemorrhage; Humans; Inappropriate Prescribing; Stroke

To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS).. A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI).. Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis.. Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Cilostazol; Humans; Myocardial Infarction; Odds Ratio; Recurrence; Risk Assessment; Risk Factors; Stents; Stroke; Tetrazoles; Time Factors; Treatment Outcome

There has been a significant increase in obesity rates worldwide with the corresponding surge in diabetes. Diabetes causes various microvascular and macrovascular changes often culminating in major clinical complications, 1 of which, is stroke. Although gains have been made over the last 2 decades in reducing the burden of stroke, the recent rise in rates of diabetes threatens to reverse these advances. Of the several mechanistic stroke subtypes, individuals with diabetes are especially susceptible to the consequences of cerebral small vessel diseases. Hyperglycemia confers greater risk of stroke occurrence. This increased risk is often seen in individuals with diabetes and is associated with poorer clinical outcomes (including higher mortality), especially following ischemic stroke. Improving stroke outcomes in individuals with diabetes requires prompt and persistent implementation of evidence-based medical therapies as well as adoption of beneficial lifestyle practices.

Topics: Cardiovascular Agents; Diabetes Mellitus; Humans; Hypoglycemic Agents; Insulin Resistance; Risk Factors; Risk Reduction Behavior; Stroke; Treatment Outcome

Cardiovascular disease (CVD) mortality in the UK is declining; however, CVD burden comes not only from deaths, but also from those living with the disease. This review uses national datasets with multiple years of data to present secular trends in mortality, morbidity, and treatment for all CVD and specific subtypes within the UK. We produced all-ages and premature age-standardised mortality rates by gender, standardised to the 2013 European Standard Population, using data from the national statistics agencies of the UK. We obtained data on hospital admissions from the National Health Service records, using the main diagnosis. Prevalence data come from the Quality and Outcome Framework and national surveys. Total CVD mortality declined by 68% between 1980 and 2013 in the UK. Similar decreases were seen for coronary heart disease and stroke. Coronary heart disease prevalence has remained constant at around 3% in England and 4% in Scotland, Wales, and Northern Ireland. Hospital admissions for all CVD increased by over 46 000 between 2010/2011 and 2013/2014, with more than 36 500 of these increased admissions for men. Hospital admission trends vary by country and CVD condition. CVD prescriptions and operations have increased over the last decade. CVD mortality has declined notably for both men and women while hospital admissions have increased. CVD prevalence shows little evidence of change. This review highlights that improvements in the burden of CVD have not occurred equally between the four constituent countries of the UK, or between men and women.

Topics: Adolescent; Adult; Age Distribution; Age of Onset; Aged; Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Female; Health Status Disparities; Healthcare Disparities; Hospitalization; Humans; Male; Middle Aged; Practice Patterns, Physicians'; Prevalence; Risk Factors; Sex Distribution; Stroke; Time Factors; United Kingdom; Young Adult

Up to 40% of ischaemic strokes are cryptogenic. A strong association between cryptogenic stroke and the prevalence of patent foramen ovale (PFO) suggests paradoxical embolism via PFO as a potential cause. Randomized trials failed to demonstrate superiority of PFO closure over medical therapy.. Randomized trials comparing percutaneous PFO closure against medical therapy or devices head-to-head published or presented by March 2013 were identified through a systematic search. We performed a network meta-analysis to determine the effectiveness and safety of PFO closure with different devices when compared with medical therapy. We included four randomized trials (2963 patients with 9309 patient-years). Investigated devices were Amplatzer (AMP), STARFlex (STF), and HELEX (HLX). Patients allocated to PFO closure with AMP were less likely to experience a stroke than patients allocated to medical therapy [rate ratio (RR) 0.39; 95% CI: 0.17-0.84]. No significant differences were found for STF (RR 1.01; 95% CI: 0.44-2.41), and HLX (RR, 0.71; 95% CI: 0.17-2.78) when compared with medical therapy. The probability to be best in preventing strokes was 77.1% for AMP, 20.9% for HLX, 1.7% for STF, and 0.4% for medical therapy. No significant differences were found for transient ischaemic attack and death. The risk of new-onset atrial fibrillation was more pronounced for STF (RR 7.67; 95% CI: 3.25-19.63), than AMP (RR 2.14; 95% CI: 1.00-4.62) and HLX (RR 1.33; 95%-CI 0.33-4.50), when compared with medical therapy.. The effectiveness of PFO closure depends on the device used. PFO closure with AMP appears superior to medical therapy in preventing strokes in patients with cryptogenic embolism.

Topics: Adult; Atrial Fibrillation; Balloon Occlusion; Cardiovascular Agents; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Humans; Male; Randomized Controlled Trials as Topic; Septal Occluder Device; Stroke; Treatment Outcome

Our aim was to describe the incidence and predictors of stroke in patients who have heart failure without atrial fibrillation (AF).. We pooled 2 contemporary heart failure trials, the Controlled Rosuvastatin in Multinational Trial Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza cardiaca-Heart Failure trial (GISSI-HF). Of the 9585 total patients, 6054 did not have AF. Stroke occurred in 165 patients (4.7%) with AF and in 206 patients (3.4%) without AF (rates 16.8/1000 patient-years and 11.1/1000 patient-years, respectively). Using Cox proportional-hazards models, we identified the following independent predictors of stroke in patients without AF (ranked by χ(2) value): age (hazard ratio, 1.34; 95% confidence interval, 1.18-1.63 per 10 years), New York Heart Association class (1.60, 1.21-2.12 class III/IV versus II), diabetes mellitus treated with insulin (1.87, 1.22-2.88), body mass index (0.74, 0.60-0.91 per 5 kg/m(2) up to 30), and previous stroke (1.81, 1.19-2.74). N-terminal pro B-type natriuretic peptide (available in 2632 patients) was also an independent predictor of stroke (hazard ratio, 1.31; 1.11-1.57 per log unit) when added to this model. With the use of a risk score formulated from these predictors, we found that patients in the upper third of risk had a rate of stroke that approximated the risk in patients with AF.. A small number of demographic and clinical variables identified a subset of patients who have heart failure without AF at a high risk of stroke.

Topics: Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Benzimidazoles; Biomarkers; Biphenyl Compounds; Cardiovascular Agents; Diabetes Mellitus, Type 1; Fatty Acids, Omega-3; Female; Fluorobenzenes; Follow-Up Studies; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kaplan-Meier Estimate; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Proportional Hazards Models; Pyrimidines; Randomized Controlled Trials as Topic; Risk Factors; Rosuvastatin Calcium; Stroke; Stroke Volume; Sulfonamides; Tetrazoles

Three innovative pharmaceuticals which might play an important role in the field of cardiology in the near future were recently tested in large clinical studies. Serelaxin, a vasoactive hormone peptide that is produced during pregnancy, reduces vessel resistance, increases cardiac output, and improves renal function. Lately, it was demonstrated that serelaxin significantly reduces congestion symptoms in patients with acute heart failure. As a secondary endpoint the mortality at day 180 was reduced. Therefore, serelaxin seems to be a promising new drug for the treatment of acute heart failure which might have a prognostic impact. Edoxaban is a selective factor Xa inhibitor, which inhibits thrombin production and thrombus formation. Two recently published studies reported that edoxaban is at least as effective as the vitamin K antagonist warfarin in prevention and treatment of venous thromboembolism and in the prevention of stroke and systemic embolism due to nonvalvular atrial fibrillation. Compared to warfarin, edoxaban significantly exhibited less frequent severe bleeding complications. Edoxaban will probably soon be the fourth new oral anticoagulant available for patients. The serine protease proprotein convertase subtilisin/kexin 9 (PCSK9) reduces the ability of the liver to bind low-density lipoprotein cholesterol (LDL-C) and to remove it from the circulation. Recently, a monoclonal antibody for PCSK9 was developed which induces a LDL-C plasma level reduction up to 73 % and also decreases lipoprotein(a) and apolipoprotein B. PCSK9 inhibition is a promising new mechanism for LDL-C reduction and the corresponding drug will be presumably approved soon by the regulatory authorities.

Topics: Antibodies, Monoclonal; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Diseases; Cholesterol, LDL; Clinical Trials, Phase III as Topic; Cyclophosphamide; Drug Approval; Drugs, Investigational; Female; Heart Failure; Humans; Hypercholesterolemia; Pregnancy; Proprotein Convertase 9; Proprotein Convertases; Recombinant Proteins; Relaxin; Serine Endopeptidases; Stroke; Venous Thromboembolism

Stroke is a disease with significant morbidity, mortality, and economic and social impacts. It is a complex entity whose pathogenesis involves multiple environmental and genetic factors, with the latter having a role in up to 50% of strokes. The objective of the review is to analyze the available methods for the genetic diagnosis including linkage studies of variation in copy number, gene - candidate approximations, or whole genome (GWAS) and polymorphisms associated with its pathogenesis. We describe several single nucleotide polymorphisms (SNPs) associated with stroke in association studies and GWAS such as SNPs of angiotensin, the aldosterone system, paraoxonases, nitric oxide, coagulation, and fibrinolysis system, among others. We also analyze the role of certain polymorphisms in the phenotype of the carotid plaque, intracranial aneurysms and lobar hemorrhages. Pharmacogenomic aspects in which SNPs affect the response and safety regarding the use of different drugs are also described. Several SNPs that significantly contribute to the risk of stroke are also described. The advent of techniques like GWAS has contributed to the understanding of genetics and pharmacogenomics of stroke.

Topics: Biotransformation; Cardiovascular Agents; Cardiovascular Diseases; Gene Dosage; Genetic Linkage; Genetic Predisposition to Disease; Genome-Wide Association Study; Humans; Molecular Diagnostic Techniques; Pharmacogenetics; Polymorphism, Single Nucleotide; Stroke

Cardiovascular disease (CVD) remains still the leading cause of death in the United States, and it is estimated to be the leading cause of death in the developing countries by 2020. In addition, the modifiable cardiovascular risk factors (CVRFs), hypertension, hypercholesterolemia, diabetes, and obesity, have increased significantly and by 2020 will account for 80% of all CVD deaths worldwide. Because the CVD and stroke risk increases significantly for subjects aged >50 years, it has been proposed to treat these subjects with a polypill containing 4 to 5 drugs, which is known to reduce the CVRFs for all subjects aged ≥55 years with an estimated reduction of CVD and stroke by 80%. However, this proposal is neither practical nor cost-effective, because it will involve a large number of subjects. Some investigators suggest to incorporate the coronary artery calcium score (CACS) with the Framingham Risk Score (FRS) to reduce the number of subjects who will benefit from the polypill. They have shown that patients with a CACS = 0 at age 50 years will derive no benefit from the polypill regardless of existing CVRFs, whereas those with a CACS of >100 will derive the best benefit. This strategy will reduce the number of qualified subjects for treatment with the polypill by 60%. Greater benefits will be derived with the combination of CACS and FRS. Additionally, other issues will have to be considered before approval of a polypill, and these issues will be discussed in this concise review. In conclusion, a polypill treatment strategy may be effective in the prevention of CVD and stroke, but, to be cost-effective, it may be reasonable to target patients with a high CACS and FRS.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Drug Combinations; Global Health; Humans; Incidence; Primary Prevention; Risk Factors; Stroke; Survival Rate

Topics: Anticoagulants; Cardiovascular Agents; Health Knowledge, Attitudes, Practice; Humans; Risk Assessment; Secondary Prevention; Stroke

Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis.

Topics: Cardiovascular Agents; Carotid Stenosis; Evidence-Based Medicine; Humans; Patient Compliance; Risk Factors; Risk Reduction Behavior; Stroke; Treatment Outcome

To determine the comparative effectiveness of exercise versus drug interventions on mortality outcomes.. Metaepidemiological study.. Meta-analyses of randomised controlled trials with mortality outcomes comparing the effectiveness of exercise and drug interventions with each other or with control (placebo or usual care).. Medline and Cochrane Database of Systematic Reviews, May 2013.. Mortality.. We combined study level death outcomes from exercise and drug trials using random effects network meta-analysis.. We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent exercise trials, our review collectively included 305 randomised controlled trials with 339,274 participants. Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14,716 participants were randomised to physical activity interventions in 57 trials. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). Inconsistency between direct and indirect comparisons was not significant.. Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

Topics: Anticoagulants; Cardiovascular Agents; Comparative Effectiveness Research; Confounding Factors, Epidemiologic; Coronary Disease; Diuretics; Exercise Therapy; Female; Heart Failure; Humans; Hypoglycemic Agents; Male; Mortality; Odds Ratio; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Prediabetic State; Randomized Controlled Trials as Topic; Research Design; Stroke

The scientific literature clearly establishes the occurrence of cardiovascular (CV) accidents and myocardial ischemic episodes is unevenly distributed during the 24 h. Such temporal patterns result from corresponding temporal variation in pathophysiologic mechanisms and cyclic environmental triggers that elicit the onset of clinical events. Moreover, both the pharmacokinetics and pharmacodynamics of many, though not all, CV medications have been shown to be influenced by the circadian time of their administration, even though further studies are necessary to better clarify the mechanisms of such influence on different drug classes, drug molecules, and pharmaceutical preparations. Twenty-four-hour rhythmic organization of CV functions is such that defense mechanisms against acute events are incapable of providing the same degree of protection during the day and night. Instead, temporal gates of excessive susceptibility exist, particularly in the morning and to a lesser extent evening (in diurnally active persons), to aggressive mechanisms through which overt clinical manifestations may be triggered. When peak levels of critical physiologic variables, such as blood pressure (BP), heart rate (HR), rate pressure product (systolic BP × HR, surrogate measure of myocardial oxygen demand), sympathetic activation, and plasma levels of endogenous vasoconstricting substances, are aligned together at the same circadian time, the risk of acute events becomes significantly elevated such that even relatively minor and usually harmless physical and mental stress and environmental phenomena can precipitate dramatic life-threatening clinical manifestations. Hence, the delivery of CV medications needs to be synchronized in time, i.e., circadian time, in proportion to need as determined by established temporal patterns in risk of CV events, and in a manner that averts or minimizes undesired side effects.

Topics: Aortic Aneurysm; Arrhythmias, Cardiac; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cardiovascular Agents; Cardiovascular Diseases; Circadian Rhythm; Heart Rate; Humans; Myocardial Ischemia; Myocardium; Stroke; Takotsubo Cardiomyopathy; Time Factors

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Topics: Amaurosis Fugax; Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Hemodynamics; Humans; Ischemic Attack, Transient; Patient Selection; Predictive Value of Tests; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Because of its high recurrence rate, active secondary prevention is mandatory once an episode of stroke has occurred. In non-cardioembolic stroke, in addition to lifestyle changes and to targeted treatments, current guidelines recommend aspirin, clopidogrel or aspirin+extended-release dipyridamole. In cardioembolic stroke (due to atrial fibrillation or flutter [AF]), vitamin K antagonists (VKAs) are recommended in most of patients. A favorable risk/benefit ratio of these treatments has been demonstrated also in elderly patients. However, registry data emphasize that such interventions are often under-used, especially in AF patients. A poor knowledge of current guidelines may play a role in hampering their application in clinical practice. The risk of major bleeding associated with antithrombotic drugs, their inherent limitations, such as socio-demographic (age >80 years, living alone) and clinical (previous or recent bleeding, trauma, cancer, dementia) features, may account for the gap between current guidelines for stroke/TIA prevention and clinical practice. The objective of the present report is to evaluate the gap between current recommendations/guidelines for stroke/TIA prevention and clinical practice (registry findings). In our opinion new antithrombotic drugs and detailed educational programs (especially devoted to general practitioners and to some medical specialists), concerning efficacy, safety and limitations of these strategies, are needed to better manage stroke epidemics in the third millennium.

Topics: Anticoagulants; Attitude of Health Personnel; Cardiovascular Agents; Evidence-Based Medicine; Fibrinolytic Agents; Guideline Adherence; Health Knowledge, Attitudes, Practice; Humans; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome

The management of atrial fibrillation has evolved greatly in the past few years, and many areas have had substantial advances or developments. Recognition of the limitations of aspirin and the availability of new oral anticoagulant drugs that overcome the inherent drawbacks associated with warfarin will enable widespread application of effective thromboprophylaxis with oral anticoagulants. The emphasis on stroke risk stratification has shifted towards identification of so-called truly low-risk patients with atrial fibrillation who do not need antithrombotic therapy, whereas oral anticoagulation therapy should be considered in patients with one or more risk factors for stroke. New antiarrhythmic drugs, such as dronedarone and vernakalant, have provided some additional opportunities for rhythm control in atrial fibrillation. However, the management of the disorder is increasingly driven by symptoms. The availability of non-pharmacological approaches, such as ablation, has allowed additional options for the management of atrial fibrillation in patients who are unsuitable for or intolerant of drug approaches.

Topics: Administration, Oral; Algorithms; Anti-Arrhythmia Agents; Anticoagulants; Aspirin; Atrial Fibrillation; Cardiac Pacing, Artificial; Cardiovascular Agents; Catheter Ablation; Decision Trees; Electric Countershock; Humans; Patient-Centered Care; Risk Factors; Stroke; Warfarin

The management of carotid artery disease includes both modifications in life style as well treatment of vascular risk factors. However, strict risk factor modification, including improved antihypertensive therapy, lipid management, smoking cessation, and antiplatelet therapy, promise for reducing the vascular event rate in patients with carotid atherosclerosis. The best medical management for stroke prevention was highlighted in clinical practice guidelines issued jointly in 2006 by the American Heart Association and the American Stroke Association, and co-sponsored by the Council on Cardiovascular Radiology and Intervention and the American Academy of Neurology. Lowering blood pressure to a target below 120/80 mm Hg by life style interventions and antihypertensive treatment. Glucose control to near-normoglycemic levels (target hemoglobin A1C ≤7%) is recommended among diabetics to reduce micro-vascular complications and, with lesser certainty, macrovascular complications. The primary objective of this review is to summarize the current evidence and standards for the advanced diagnostic and management strategies used in asymptomatic and symptomatic patients with carotid atherosclerosis.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Artery Diseases; Humans; Hypoglycemic Agents; Hypolipidemic Agents; Practice Guidelines as Topic; Primary Prevention; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stroke; Treatment Outcome

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people, the search for a patent foramen ovale (PFO) has become standard. In stroke of the elderly, atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO-related stroke over time is controversial and so is its prevention by device closure. The association of proximal aortic plaques in arteries subtending the brain and stroke is considered strong, ignoring that it is as putative as that of the PFO. Statins can prevent progression of such plaques. Antiplatelet agents in asymptomatic and surgical endarterectomy in symptomatic patients or highly ulcerated lesions are the treatment of choice. Stenting with protection devices was shown competitive in selected patients.

Topics: Anticoagulants; Aortic Diseases; Balloon Occlusion; Cardiovascular Agents; Carotid Stenosis; Foramen Ovale, Patent; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Plaque, Atherosclerotic; Platelet Aggregation Inhibitors; Prosthesis Design; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Septal Occluder Device; Stents; Stroke

Atrial fibrillation (AF) is the most frequent heart arrhythmia and causes a substantial proportion of ischemic strokes. AF has a marked impact on stroke severity, as well as on morbidity and mortality in these patients. The importance of AF as an etiologic factor of stroke increases in the elderly and in the last few years its detection has increased. The presence of AF leads to more severe initial neurological involvement, longer hospitalization, greater disability and a lower probability of discharge to home. In addition, AF is an independent risk factor for mortality, especially in women and the elderly. All these factors lead to a higher social and economic impact among stroke patients with AF.

Topics: Atrial Fibrillation; Brain Damage, Chronic; Brain Ischemia; Cardiovascular Agents; Cost of Illness; Female; Health Care Costs; Health Expenditures; Hospitalization; Humans; Intracranial Embolism; Male; Prevalence; Quality of Life; Risk Factors; Social Adjustment; Social Change; Socioeconomic Factors; Stroke

Intracranial artery stenosis (ICAS) is a narrowing of an intracranial artery, which is a common etiology for ischemic stroke. In this commentary, we review key aspects of the discrimination between non-stroke controls and ischemic stroke patients on the background of phospholipid ω3-fatty acid (DHA, EPA) composition. The discussion is embedded in the presentation of general effects of long-chain ω3 polyunsaturated fatty acids (PUFAs) in cardio-cerebro-vascular diseases (CCVDs) and Alzheimer dementia (AD).. ICAS is a common stroke subtype and has emerged as a major factor in recurrent stroke and vascular mortality. DHA and EPA are important fatty acids to distinguish between NCAS (no cerebral arteriosclerotic stenosis) and ICAS in stroke. The risk of ICAS is inversely correlated with the DHA content in phospholipids. Furthermore, a mechanistic explanation has been proposed for the beneficial effects of PUFAs in CCVDs and AD.. Whereas the beneficial effects of EPA/DHA for cardiovascular diseases and stroke seem to be beyond question, preventive effects in patients with very mild cognitive dysfunction and beginning Alzheimer's disease undoubtedly need confirmation by larger clinical trials. A collaborative international basic science approach is warranted considering cautiously designed studies in order to avoid ethical problems.

Topics: Alzheimer Disease; Cardiovascular Agents; Cardiovascular Diseases; Cerebrovascular Disorders; Constriction, Pathologic; Dementia, Vascular; Diet; Dietary Supplements; Fatty Acids, Omega-3; Humans; Intracranial Arterial Diseases; Nutrition Policy; Stroke

Epoxyeicosatrienoic acids (EETs) are cytochrome P450 (CYP450) products of arachidonic acid and EETs are endogenous lipid mediators synthesized by the vascular endothelium which perform important biological functions, including vasodilation, anti-inflammation, antimigratory, and cellular signaling regulations. However, EETs are rapidly degraded by soluble epoxide hydrolase (sEH) to the corresponding diols: dihydroxyeicosatrienoic acids (DHETs), which have little active in causing vasorelaxation. A number of studies have supported that the inhibition of sEH (sEHIs) had cardiovascular protective effects in hypertension, cardiac hypertrophy, atherosclerosis, ischemia-reperfusion injury, and ischemic stroke. Moreover, sEHIs could slow the progression of inflammation, protect end-organ damage and prevent ischemic events, also, attenuate endothelial dysfunction, suggesting that the pharmacological blockade of sEH might provide a broad and novel avenue for the treatment of many cardiovascular diseases.

Topics: Animals; Brain Ischemia; Cardiomegaly; Cardiovascular Agents; Cardiovascular Diseases; Enzyme Inhibitors; Epoxide Hydrolases; Humans; Hypertension; Polymorphism, Genetic; Reperfusion Injury; Risk; Stroke

Stroke is a major cause of death and disability worldwide. Without improvements in prevention, the burden will increase during the next 20 years because of the ageing population, especially in developing countries. Major advances have occurred in secondary prevention during the past three decades, which demonstrate the broader potential to prevent stroke. We review the main medical treatments that should be considered for most patients with transient ischaemic attack or ischaemic stroke in the acute phase and the long term, and draw attention to recent developments.

Topics: Acute Disease; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Cholesterol, HDL; Cholesterol, LDL; Chronic Disease; Developing Countries; Dyslipidemias; Fibrinolytic Agents; Humans; Hypertension; Hypolipidemic Agents; Ischemic Attack, Transient; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Time Factors; Triage

The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.. Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).. Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.. Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.

Topics: Adult; Aged; Aspirin; Cardiovascular Agents; Cause of Death; Female; Gastrointestinal Hemorrhage; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Primary Prevention; Randomized Controlled Trials as Topic; Risk Assessment; Stroke

Medical treatment has a pivotal role in the treatment of patients with occlusive carotid artery disease. Large trials have provided the justification for operative treatment besides medical treatment in patients with recent significant carotid artery stenosis two decades ago. Since then, medical therapy has evolved tremendously. Next to aspirin, antiplatelet regimens acting on a different level in the modulation of platelet aggregation have made their entry. Moreover, statin therapy has been introduced. These changes among others in secondary stroke prevention, along with better understanding in life-style adjustments and perioperative medical management, have led to a decrease in stroke recurrence. Secondary prevention is therefore now the most important pillar of medical therapy. It consists of antiplatelet therapy, statins and blood pressure lowering agents in all patients. Small adjustments are recommended for those patients referred for invasive treatment. Moreover, long-term medical treatment is imperative. In this article, we summarize current evidence in literature regarding medical management in patients with previous stroke or TIA.

Topics: Antihypertensive Agents; Cardiovascular Agents; Carotid Stenosis; Drug Therapy, Combination; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome

Carotid endarterectomy (CEA) has been repeatedly described as a safe and efficacious procedure to provide a stroke-risk reduction benefit in both symptomatic and asymptomatic cases. Contemporary outcomes are acceptable using the large-scale randomized trials as a metric of success. Class I and II data can be applied to improve the care process of patients undergoing CEA. Myocardial infarction remains the most significant nonstroke complication; however, there is no significant benefit to noninvasive stress testing in patients with clinically stable disease. Perioperative beta-blockade may offer up to a 10-fold reduction in the rate of perioperative myocardial infarction, but deleterious effects are attributable to high-dose regimens. Angiotensin blockade has been shown to reduce cardiovascular mortality in patients with atherosclerosis by up to 25%, although few studies have examined these agents directly in carotid surgery patients. Statins are beneficial to patients undergoing CEA with trials demonstrating up to a 3% absolute reduction in the incidence of stroke following CEA. Aspirin therapy is associated with an up to 7% absolute reduction in early stroke following CEA; however, the efficacy of combination or high-dose antiplatelet therapy remains ill-defined. A treatment strategy that involves perioperative medical optimization is likely to improve surgical outcomes and long-term cardiovascular risk for patients undergoing CEA.

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Carotid Artery Diseases; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Infarction; Perioperative Care; Platelet Aggregation Inhibitors; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome

We assessed the prevalence, and potential impact of, trials of pharmacological agents for acute stroke that were completed but not published in full. Failure to publish trial data is to be deprecated as it sets aside the altruism of participants' consent to be exposed to the risks of experimental interventions, potentially biases the assessment of the effects of therapies, and may lead to premature discontinuation of research into promising treatments.. We searched the Cochrane Stroke Group's Specialised Register of Trials in June 2008 for completed trials of pharmacological interventions for acute ischaemic stroke, and searched MEDLINE and EMBASE (January 2007 - March 2009) for references to recent full publications. We assessed trial completion status from trial reports, online trials registers and correspondence with experts.. We identified 940 trials. Of these, 125 (19.6%, 95% confidence interval 16.5-22.6) were completed but not published in full by the point prevalence date. They included 16,058 participants (16 trials had over 300 participants each) and tested 89 different interventions. Twenty-two trials with a total of 4,251 participants reported the number of deaths. In these trials, 636/4251 (15.0%) died.. Our data suggest that, at the point prevalence date, a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field was not published in full. Over 16,000 patients had given informed consent and were exposed to the risks of therapy. Responsibility for non-publication lies with investigators, but pharmaceutical companies, research ethics committees, journals and governments can all encourage the timely publication of trial data.

Topics: Brain Ischemia; Cardiovascular Agents; Clinical Trials as Topic; Evidence-Based Medicine; Humans; Information Dissemination; Informed Consent; Publishing; Risk Assessment; Stroke; Treatment Outcome

Stroke is a leading cause of morbidity and mortality in the developed world. Although the rates of stroke have decreased in North America, there are significant areas of risk stratification and management that can be improved. Hypertension is the most significant and perhaps most modifiable risk factor for stroke. Carotid atherosclerotic disease is associated with 15% of ischemic strokes. Although carotid endarterectomy (CEA) remains a recommendation for significant symptomatic carotid stenosis, controversy continues in the management of asymptomatic and recurrent carotid stenosis. Medical management options and effectiveness has significantly improved since the early CEA trials were published. Optimal medical management now must incorporate aggressive risk factor reduction measures, particularly with antihyperlipidemic therapy. Improved understanding of the natural history of carotid atherosclerosis is necessary to improve the application of management strategies.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Evidence-Based Medicine; Humans; Recurrence; Risk Assessment; Risk Factors; Risk Reduction Behavior; Smoking Cessation; Stroke; Treatment Outcome

Despite randomized controlled trials demonstrating the superiority of carotid endarterectomy over medical management in the prevention of stroke in asymptomatic patients with severe carotid artery stenosis, considerable controversy remains with regard to selecting the appropriate asymptomatic patient for carotid intervention. Adding to the complexity of this issue is the fact that the extensive existing literature on this topic is heterogeneous, with trials having used varying definitions of high-grade stenosis, inclusion criteria for patients, and outcome measurements. The current article will review the existing randomized controlled trials on this topic, data regarding the risk of stroke in asymptomatic patients with severe stenosis, data regarding subsets of asymptomatic patients that may be at a higher-than-average risk of future stroke, and data regarding the efficacy of current medical therapy on the risk of stroke in asymptomatic patients with high-grade stenosis. Ultimately, the challenge for clinicians is to ensure that asymptomatic patients with the highest risk of future stroke are offered carotid revascularization and that the intervention is performed with the lowest possible complication rate, in order to maintain the benefit of prophylactic treatment.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Carotid endarterectomy (CEA) has long been considered the "gold standard" in the treatment of patients with symptomatic or asymptomatic carotid stenosis. However, the utility of this treatment modality in medical or surgical "high-risk" patients remains in question. Numerous clinical trials have demonstrated that carotid angioplasty and stenting (CAS) is not inferior to CEA. Furthermore, there are also increasing data that show that best medical therapy is becoming more effective in preventing strokes and in a more cost-effective manner than carotid interventions. With this in mind, there is now ample evidence to suggest that in a certain subgroup of patients, CEA may not be indicated, and in fact, CAS or observation with best medical therapy is preferred.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Stents; Stroke; Treatment Outcome

Numerous neuroprotective agents have proven effective in animal stroke studies, but every drug has failed to achieve its primary outcome when brought forward to clinical trials. We analyzed the quality and adequacy of animal studies supporting the efficacy of NXY-059 and other neuroprotective agents that are currently being investigated in phase II/III trials.. We conducted a systematic search of all neuroprotective drugs in Phase II or III trials and collected data from animal studies of focal cerebral ischemia testing agents systemically administered within 24 hours of occlusion. The methodological rigor of each individual study was evaluated using 5 criteria derived from the STAIR guidelines. The adequacy of the preclinical "package" for each drug was then evaluated by combining the results of all studies for each drug to determine which of a further 5 STAIR criteria were met before moving forward from animal to human studies.. Our search yielded 13 agents of which 10 had published data in peer-reviewed journals. There is substantial within-drug variability in the quality of preclinical studies as well as substantial variation in the completeness of the collective preclinical literature for different drugs. There has been little or no improvement in the quality of animal studies since NXY-059, and current agents have not been subjected to a more complete preclinical evaluation.. There is significant heterogeneity in the quality of animal testing for neuroprotective agents in stroke. Drugs in the post-SAINT era have not been subjected to more thorough preclinical evaluation.

Topics: Acute Disease; Animals; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Clinical Trials, Phase II as Topic; Clinical Trials, Phase III as Topic; Disease Models, Animal; Humans; Neuroprotective Agents; Research; Research Design; Risk; Stroke

Cardioembolic stroke accounts for one third of all ischemic strokes, and atrial fibrillation (AF) is the cardiac source of emboli in 50% of them. However, the absolute risk of stroke associated with AF has enormous variability, and several clinical risk stratification schemes have been proposed. One of the most validated and used in clinical practice is the CHADS2 index, characterized by its simplicity and rapid application. Current recommendations about antithrombotic therapy in AF patients are based on assessment of annual risk of stroke; thus, antiaggregation is indicated in patients with a low risk, and anticoagulation is prescribed when annual risk is greater than 2.5%. Relevant studies comparing rate and rhythm control do not defend achievement and maintenance of sinus rhythm as a routine management of AF patients and demonstrate that rate control is comparable or even better than rhythm control in terms of survival and quality of life. Optimal control of blood pressure is a relevant factor in preventing cardioembolic stroke in AF patients, because hypertension multiplies the risk of stroke by 12. Antihypertensive drugs such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers proved to reduce AF recurrences, especially in the context of left ventricular dysfunction and ventricular hypertrophy.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Cardiovascular Agents; Embolism; Fibrinolytic Agents; Heart Diseases; Humans; Hypertension; Patient Care Team; Patient Selection; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome

Chronic cardiopulmonary disease typically induces and maintains (over)activation of several phylogenetically old adaptational and defensive mechanisms. Activation was usually needed for a limited period during acute danger or injury. In chronic disease conditions, however, those mechanisms are kept activated for longer periods. Eventually, irreversible damage is done and this contributes to impaired function and worse prognosis in a variety of chronic disease. Landmark trials in chronic heart failure have provided robust evidence for prognostic benefit for neurohormonal antagonists. Retrospective and epidemiological data for their beneficial effect in chronic obstructive pulmonary disease begin to accumulate and new fields (e.g. cancer and stroke) could be pending in the future.

Topics: Cachexia; Cardiovascular Agents; Clinical Trials as Topic; Comorbidity; Heart Failure; Humans; Inflammation; Neurotransmitter Agents; Pulmonary Disease, Chronic Obstructive; Renin-Angiotensin System; Risk Factors; Stroke

Topics: Acute Disease; Age Factors; Aged, 80 and over; Animals; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Comorbidity; Contraindications; Critical Care; Heart Valve Prosthesis Implantation; Humans; Risk Factors; Stroke; Time Factors; Treatment Outcome; Vascular Surgical Procedures

The continued failure in approving new drugs for treatment of acute stroke has been recently set back by the failure of the NXY-059 (Stroke-Acute Ischemic NXY Treatment (SAINT) II) trial. The disappointment was heightened by the latter study being viewed as a most promising compound for stroke drug development program based on the preclinical data. Since the SAINT I/II development program included many of the STAIR (Stroke Therapy Academic Industry Round table) guidelines, yet have still failed to achieve the expected efficacy, there is a clear need to continue and analyze the path forward for stroke drug discovery. To this end, this review calls for a consortium approach including academia, government (FDA/NIH), and pharmaceutical industry partnerships to define this path. It is also imperative that more attention is given to the evolving discipline of Translational Medicine. A key issue in this respect is the need to devote more attention to the characteristics of the drug candidate nature-target interaction, and its relationship to pharmacodynamic treatment end points. It is equally important that efforts are spent to prove that phenotypic outcomes are linked to the purported mechanism of action of the compound. Development of technologies that allows a better assessment of these parameters, especially in in vivo models are paramount. Finally, rational patient selection and new outcome scales tailored in an adaptive design model must be evaluated.

Topics: Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Clinical Trials, Phase I as Topic; Clinical Trials, Phase II as Topic; Drug Approval; Drug Design; Drug Industry; Endpoint Determination; Guidelines as Topic; Humans; Models, Cardiovascular; National Institutes of Health (U.S.); Patient Selection; Stroke; Treatment Outcome; United States; United States Food and Drug Administration

Acute ischemic stroke (AIS) is a significant cause of death and disability in the United States. It has been 10 years since tissue plasminogen activator became the first medication approved by the US Food and Drug Administration for treatment for AIS. However, this treatment simply reopens arteries. The identification of deleterious cellular reactions that occur secondary to cerebral ischemia has led investigators to search for neuroprotection strategies to complement reperfusion. More than 100 human trials, including a handful of phase III trials, had failed to produce an efficacious neuroprotective agent. In 2006, the first positive trial of neuroprotection was published: the SAINT I (Stroke-Acute Ischemic NXY Treatment) study. In February 2008, the SAINT II study was published, indicating that NXY-059 was not effective for AIS treatment.

Topics: Acute Disease; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Clinical Trials as Topic; GABA Agonists; Humans; Hypothermia; N-Methylaspartate; Narcotic Antagonists; Neuroprotective Agents; Stroke; Tissue Plasminogen Activator

After a stroke or transient ischaemic attack (TIA) there is a high risk of stroke, particularly in the early days and weeks, and of other serious vascular events. Several preventive medical treatments can reduce these risks; starting them as early as possible will maximise the absolute risk reduction, as long as the diagnosis is secure, there is no known or suspected net harm from treatment, and they are acceptable to the patient. Medical treatments with clear evidence of benefit include: lowering blood pressure after all types of stroke or TIA; lowering blood cholesterol with a statin after ischaemic stroke or TIA; antiplatelet treatment after ischaemic stroke or TIA; and warfarin instead of antiplatelet treatment in patients with ischaemic stroke or TIA who have atrial fibrillation and no contraindications to anticoagulation. Lifestyle changes (for example, stopping smoking, reducing excess alcohol intake, adopting a healthy diet) and careful management of diabetes are also important.

Topics: Blood Pressure; Cardiovascular Agents; Cholesterol; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Myocardial Infarction; Recurrence; Risk Factors; Stroke; Vascular Diseases

The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study is the first, and, so far, the only endpoint trial in patients with hypertension and left ventricular hypertrophy (LVH) to show a divergent therapeutic outcome of one treatment modality over another with equivalent blood pressure control. The purpose of this article is to review post hoc sub-analyses of LIFE study data and other clinical studies that offer some insight into possible treatment-related differences contributing to the superior stroke outcome of losartan versus atenolol beyond blood pressure reduction.. Relevant randomized clinical trials and review articles were identified through a MEDLINE search of English-language articles published between 1990 and 2006 using the search terms losartan, atenolol, LIFE, hypertension, and LVH. Articles describing major clinical studies, new data, or mechanisms pertinent to the LIFE study were selected for review.. Differences in blood pressure or in the distribution of add-on medications were not evident between study groups in the LIFE study. Thus, the observed outcomes benefits favoring losartan may involve other possible mechanisms, including differential effects of losartan and atenolol on LVH regression, left atrial diameter, atrial fibrillation, brain natriuretic peptide, vascular structure, thrombus formation/platelet aggregation, serum uric acid, albuminuria, new-onset diabetes, and lipid metabolism. Alternative explanations for the LIFE study findings have also been put forward, including the choice of atenolol as an appropriate active comparator and differential effects between treatment groups on central pulse pressure. Additional clinical trials are needed to determine if the beneficial effects of losartan seen in LIFE are shared by other inhibitors of the renin-angiotensin system.. Sub-analyses of the LIFE study data suggest that losartan's stroke benefit may arise from a mosaic of mechanisms rather than a single action. Further studies are expected to continue to delineate the mechanisms of differential responses to treatments in LIFE.

Topics: Adrenergic beta-Antagonists; Angiotensin II Type 1 Receptor Blockers; Antihypertensive Agents; Atenolol; Atrial Fibrillation; Atrial Natriuretic Factor; Biomarkers; Blood Pressure; Cardiovascular Agents; Cohort Studies; Drug Utilization; Endothelium, Vascular; Follow-Up Studies; Heart Atria; Humans; Hypertension; Hypertrophy, Left Ventricular; Losartan; Models, Biological; Myocardial Infarction; Natriuretic Peptide, Brain; Peptide Fragments; Platelet Aggregation; Platelet Aggregation Inhibitors; Protein Precursors; Randomized Controlled Trials as Topic; Research Design; Risk; Risk Factors; Stroke; Thrombosis; Treatment Outcome

Treatments for spontaneous intracerebral, thrombolytic-induced and intraventricular hemorrhages (IVH) are still at the preclinical or early clinical investigational stages. There has been some renewed interest in the use of surgical evacuation surgery or thrombolytics to remove hematomas, but these techniques can be used only for specific types of brain bleeding. The STICH (Surgical Trial in Intracerebral Haemorrhage) clinical trials should provide some insight into the potential for such techniques to counteract hematoma-induced damage and subsequently, morbidity and mortality. More recently, clinical trials (ATACH [Antihypertensive Treatment in Acute Cerebral Hemorrhage] and INTERACT [Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial]) have begun testing whether or not regulating blood pressure affects the well-being of hemorrhage patients, but the findings thus far have not conclusively demonstrated a positive result. More promising trials, such as the early stage CHANT (Cerebral Hemorrhagic And NXY-059 Treatment) and the late stage FAST (Factor VIIa for Acute Hemorrhagic Stroke Treatment), have addressed whether or not manipulating oxidative stress and components of the blood coagulation cascade can achieve an improved prognosis following spontaneous hemorrhages. However, CHANT was halted prematurely because although it showed that the spin trap agent NXY-059 was safe, it also demonstrated that the drug was ineffective in treating acute ischemic stroke. In addition, the recombinant activated factor VII FAST trial recently concluded with only modestly positive results. Despite a beneficial effect on the primary end point of reducing hemorrhage volume, controlling the coagulation cascade with recombinant factor VIIa did not decrease the mortality rate. Consequently, Novo Nordisk has abandoned further development of the drug for the treatment of intracerebral hemorrhaging. Even though progress in hemorrhage therapy that successfully reduces the escalating morbidity and mortality rate associated with brain bleeding is slow, perseverance and applied translational drug development will eventually be productive. The urgent need for such therapy becomes more evident in light of concerns related to uncontrolled high blood pressure in the general population, increased use of blood thinners by the elderly (e.g., warfarin) and thrombolytics by acute ischemic stroke patients, respectively. The future of drug development for hemorrhage may requi

Topics: Animals; Antihypertensive Agents; Antioxidants; Benzenesulfonates; Blood Pressure; Cardiovascular Agents; Coagulants; Disease Models, Animal; Drug Design; Enzyme Inhibitors; Erythropoietin; Excitatory Amino Acid Antagonists; Factor VIIa; Hemostasis; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Intracranial Hemorrhages; Oxidative Stress; Signal Transduction; Stroke; Treatment Outcome

Prevention harbors the greatest potential for reducing the societal burden from stroke. As evidence accumulates on the multifactorial pathogenesis of vascular disease and the impact of novel combination therapies targeted at reducing recurrent vascular events, a new paradigm is emerging, which is that of multimodality vascular prevention. Knowledge of the evidence behind this strategy and the effective means for implementing it could be useful to the practicing neurologist taking care of stroke patients.. Our review presents the evidence behind the broadening therapeutic options for recurrent vascular event prevention in ischemic stroke patients whose underlying stroke pathophysiologic mechanism is either presumed to be due to atherosclerosis or who have prior evidence of systemic atherosclerosis. We elaborate on conventional and novel vascular risk factors, as well as risk factor prediction models. Therapies discussed include antithrombotics, statins, antihypertensives, surgical/endovascular treatments, and lifestyle modification. Basis for evidence (or the lack thereof), national guideline recommendations, areas of controversy, and avenues of future focus for these treatments are also discussed in this paper. Furthermore, the knowledge-treatment gap as it pertains to optimal vascular risk-factor control and appropriate initiation and maintenance of evidence-based preventive therapies is explored, and an effective hospital-based intervention involving the in-hospital initiation of these treatments prior to discharge, that may help bridge this gap, is detailed.. Neurologists should be aware that a timely, systematic, evidence-based multimodal preventive approach to atherothrombotic disease in stroke patients that transcends the continuum of care across points of service will likely increase treatment rates and improve clinical outcomes.

Topics: Cardiovascular Agents; Combined Modality Therapy; Humans; Life Style; Neurosurgical Procedures; Risk Factors; Stroke

Topics: Acute Disease; Animals; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Humans; Nitrogen Oxides; Stroke

Acute ischaemic stroke is a major health problem with no effective treatments apart from the thrombolytic recombinant tissue plasminogen activator (rt-PA), which must be given within 3h of stroke onset. However, rt-PA increases the risk of symptomatic intracranial haemorrhage and is administered to <5% of stroke patients. New perfusion-enhancing compounds are in development but the risk:benefit ratio remains to be determined. Many neuroprotective drugs have been studied but all those that reached clinical development have failed to demonstrate efficacy. However, adherence to recently published guidelines on preclinical development has resulted in one novel compound (NXY-059) demonstrating efficacy in a Phase III trial, providing encouragement for the validity of the concept of neuroprotection. There are a variety of new neuroprotective compounds in the early stages of investigation and some could prove clinically effective, provided appropriate preclinical development guidelines are observed.

Topics: Animals; Benzenesulfonates; Cardiovascular Agents; Clinical Trials as Topic; Disease Models, Animal; Humans; Nitrogen Oxides; Stroke; Thrombolytic Therapy

Stroke is an important cause of morbidity and mortality, and is an economic burden. Diabetes and obesity are two important modifiable risk factors for stroke. Patients with diabetes have a higher incidence of stroke and a poorer prognosis after stroke. Risk-factor modification is the most important aspect of prevention of stroke in diabetes and obesity. This includes lifestyle modifications and different therapeutic modalities to control conditions, such as diabetes, hypertension, dyslipidemia and arrhythmia. Recent landmark studies have shown the beneficial effects of statins in diabetic patients even with close to normal or normal low-density lipoprotein cholesterol. Obesity, which is a risk factor for diabetes, hypertension and hyperlipidemia has been shown to be an independent risk factor for stroke. Increased leptin, dysregulation of adipocyte proteins, increased insulin resistance and C-reactive protein may be factors involved in the increased incidence of cardiovascular morbidity and mortality directly related to obesity. Visceral fat is a much bigger health risk than subcutaneous fat. Lifestyle interventions and pharmacotherapeutic agents have been used to manage obesity. In morbidly obese patients, surgical intervention seems to be the best method of treatment with a long-lasting favorable metabolic outcome. In the 21st Century, with the advanced medical knowledge and the therapeutic modalities available, it should be possible to reduce the incidence of stroke associated with diabetes and obesity.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Atrial Fibrillation; Blood Glucose; Cardiovascular Agents; Carotid Stenosis; Diabetes Mellitus; Diabetic Angiopathies; Diabetic Nephropathies; Diabetic Retinopathy; Dyslipidemias; Humans; Hypertension; Insulin Resistance; Ischemic Attack, Transient; Leptin; Life Style; Lipoproteins; Obesity; Plasminogen Activator Inhibitor 1; Risk Factors; Smoking; Stroke

A variety of primary end points have been used in acute stroke trials. We focus on the modified Rankin Scale, a reliable and valid ordinal outcome measure that assesses disability on a 7-point scale.. We provide an abbreviated discussion of analytical methods for ordinal scales, and related effect size measures; we illustrate these methods and their interpretation with outcome data from the SAINT I study of NXY-059 in acute ischemic stroke.. The nonparametric Mann-Whitney statistic provides a straightforward method for analysis of the modified Rankin Scale, and incorporates associated measures of effect size. These measures are directly related to the concepts of Number Needed to Treat and Number Needed to Harm.. Our re-examination of the outcome data from the SAINT I study provides little evidence for the purported efficacy of NXY-059. More broadly, analysis and interpretation of ordinal outcome scales based on ascribed numerical values to the steps of the scale should be done cautiously. Statistical treatment of multiple primary outcome measures in acute stroke clinical trials should be established before analysis. Lastly, conflating statistical and clinical significance should be avoided.

Topics: Acute Disease; Benzenesulfonates; Biomarkers; Brain Damage, Chronic; Brain Ischemia; Cardiovascular Agents; Clinical Trials as Topic; Clinical Trials, Phase III as Topic; Disability Evaluation; Double-Blind Method; Free Radical Scavengers; Humans; Neuroprotective Agents; Neuropsychological Tests; Nitrogen Oxides; Randomized Controlled Trials as Topic; Sample Size; Severity of Illness Index; Statistics, Nonparametric; Stroke; Treatment Failure; Treatment Outcome

In part VI of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors analyze data of randomized trials comparing various approaches to the treatment of atrial fibrillation: cardioversion with subsequent use of antiarrhythmic drugs for maintenance of sinus rhythm and control of rate of ventricular rhythm with obligatory concomitant use of anticoagulants. Approach aimed at sinus rhythm maintenance by means of repetitive cardioversions and long term antiarrhythmic therapy has not been associated with lowering of mortality, rates of stroke or other thromboembolic complications. The use of antithrombotic drugs represent a sole reliable method of stroke prevention in patients with persistent and chronic AF. The paper contains consideration of indications for prescription of warfarin and aspirin to these patients.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Aspirin; Atrial Fibrillation; Cardiovascular Agents; Electric Countershock; Fibrinolytic Agents; Humans; Randomized Controlled Trials as Topic; Stroke; Thromboembolism; Warfarin

The 2 fundamental approaches to the management of atrial fibrillation (AF) are reestablishing and maintaining sinus rhythm (rhythm control) and controlling ventricular rate with atrioventricular node blocking agents (rate control). We performed a meta-analysis of randomized controlled trials comparing these strategies in patients with AF to add precision to the relative merits of both strategies on the risk of all-cause mortality and to evaluate the consistency of the results between trials.. We performed a literature search in MEDLINE (1966 to May 2003), the Cochrane Controlled Trial Registry (first quarter of 2003), and International Pharmaceutical Abstracts (1970 to May 2003). Eligible trials were randomized controlled trials comparing pharmacologic rhythm and rate control strategies as first-line therapy in patients with AF.. Five trials were identified that included a total of 5,239 patients with persistent AF or AF that was considered likely to be recurrent. No significant difference was observed between the rate and the rhythm control groups regarding all-cause mortality, although a strong trend in favor of a rate control approach was observed (13.0% vs 14.6%; odds ratio, 0.87; 95% confidence interval, 0.74-1.02; P=.09). No heterogeneity was apparent between the trials (Q value=2.97; P=.56).. In patients with persistent AF or with AF that is likely to be recurrent, a strategy of ventricular rate control, in combination with anticoagulation in appropriate patients, appears to be at least equivalent to a strategy of maintaining sinus rhythm by using currently available antiarrhythmic drugs in preventing clinical outcomes.

Topics: Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiovascular Agents; Combined Modality Therapy; Drug Therapy, Combination; Electric Countershock; Female; Heart Rate; Humans; Male; Odds Ratio; Randomized Controlled Trials as Topic; Recurrence; Stroke

Stroke continues to have a devastating impact on public health. Recent epidemiological studies suggest that stroke is becoming more common, perhaps due to the ageing of the population and increased survival of patients with cardiac disease. There are specific and well-defined risk factors in patients with stroke, the most important being hypertension. Treatment options to reverse the effect of acute ischaemic stroke are limited. The only approved therapy is intravenous tissue plasminogen activator (tPA). The disadvantage of tPA treatment is a rate of symptomatic haemorrhage of about 6%. Newer stroke prevention options are currently being investigated including statins, oestrogen, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). The challenge for physicians is to select the most effective intervention, and this depends on our knowledge of the underlying stroke mechanism and the patient's risk factors.

Topics: Aged; Aged, 80 and over; Angiotensin Receptor Antagonists; Brain Ischemia; Cardiovascular Agents; Female; Humans; Hypertension; Male; Middle Aged; Risk Factors; Stroke; United States

Topics: Adolescent; Adult; Aged; Antihypertensive Agents; Arrhythmias, Cardiac; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Calcium Channel Blockers; Cardiovascular Agents; Catecholamines; Chronotherapy; Circadian Rhythm; Clinical Trials as Topic; Cross-Over Studies; Delayed-Action Preparations; Diltiazem; Double-Blind Method; Electrocardiography, Ambulatory; Hemodynamics; Humans; Middle Aged; Multicenter Studies as Topic; Myocardial Infarction; Myocardial Ischemia; Sleep; Stroke; Verapamil

Patients with atherosclerotic renal artery stenosis may develop hypertension, recurrent pulmonary edema and chronic renal failure, but have a much higher risk of dying from stroke or myocardial infarction than of progressing to end-stage renal disease. Indeed, atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas the results of trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition, especially if their renal resistance--index before revascularization is less than 80. With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases.

Topics: Angiotensin-Converting Enzyme Inhibitors; Arteriosclerosis; Aspirin; Cardiovascular Agents; Combined Modality Therapy; Creatinine; Diagnostic Imaging; Drug Therapy, Combination; Heart Failure; Humans; Hypertension, Renovascular; Hypolipidemic Agents; Myocardial Infarction; Platelet Aggregation Inhibitors; Pulmonary Edema; Radionuclide Imaging; Renal Artery; Renal Artery Obstruction; Risk Factors; Stroke

Topics: Acute Disease; alpha-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid; Antibodies; Brain Ischemia; Calcium Channel Blockers; Cardiovascular Agents; Cell Adhesion Molecules; Clinical Trials as Topic; Cytidine Diphosphate Choline; Cytokines; Drug Therapy, Combination; Fibrinolytic Agents; Free Radical Scavengers; gamma-Aminobutyric Acid; Growth Substances; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; N-Methylaspartate; Neuroprotective Agents; Nootropic Agents; Piperidines; Stroke; Thiazoles; Thrombolytic Therapy

Drugs with the efficacy of modifying rheological properties of blood, blood vessels and their interactions are denoted by "hemorheologicals". Drugs of anti-hyperviscosemia, anti-coagulants, anti-platelet drugs, anti-thrombotics, vasodilators, endothelial cell protectors and anti-arthrosclerosis should be considered as hemorheologicals due to the actions in keeping blood fluidity and in maintaining normal vascular functions. The studies in hemorheology indicate that a tendency of hyperviscosity, hypercoagulation and being prone to thrombosis is prevalent in the elderly. Hemorheologicals are importance for and aging and life-threatening diseases. Blood stasis syndrome is a common pathological syndrome in the elderly. In traditional Chinese medicine, the treatment for the syndrome is by herbs which activates blood circulation to remove blood stasis. The herbs have the efficacy of improving hemorheological events. Therefore, the herbs are the source for developing hemorheologicals. Ligustrazine isolated from Chuangxiong is an example. It showed significant inhibition on shear induced platelet aggregation and on platelet intracellular calcium demonstrated by laser confocal microscope.

Topics: Aged; Animals; Anticoagulants; Blood Viscosity; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Fibrinolytic Agents; Hemodynamics; Hemorheology; Humans; Platelet Aggregation; Platelet Aggregation Inhibitors; Pyrazines; Rats; Rats, Wistar; Stroke; Thrombosis

The aim of this study was to examine the relationship of albuminuria to cardiovascular disease outcomes in diabetic patients undergoing treatment for stable coronary artery disease.. We analyzed data from 2176 participants of the Bypass Angioplasty Revascularization Investigation in type-2 diabetes (BARI-2D) trial, a randomized clinical trial comparing Percutaneous coronary intervention/Coronary artery bypass grafting (PCI/CABG) to medical therapy for people with diabetes. The population was stratified by baseline spot urine albumin-creatinine ratio (uACR) into normal (uACR <10 mg/g), mildly (uACR ≥10 mg/g < 30 mg/g), moderately (uACR ≥30 mg/g < 300 mg/g) and severely increased (uACR ≥300 mg/g) groups, and outcomes compared between groups. Death, myocardial infarction (MI) and/or stroke were experienced by 489 patients at a mean follow-up of 4.3 ± 1.5 years. Compared with normal uACR, mildly increased uACR was associated with a 1.4 times (P = 0.042) increase in all-cause mortality. Additionally, nonwhites with type-II diabetes and stable coronary artery disease who had mildly increased albuminuria had a Hazard ratio (HR) of 3.3 times (P = 0.028) for cardiovascular death, 3.1 times for (P = 0.002) all-cause mortality, and two times for (P = 0.015) MI during follow-up.. Mildly increased albuminuria is a significant predictor of all-cause mortality in those with type-II diabetes mellitus and stable coronary artery disease, as well as for cardiovascular events those who are nonwhites.

Topics: Aged; Albuminuria; Brazil; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus, Type 2; Diabetic Nephropathies; Europe; Female; Humans; Male; Middle Aged; Myocardial Infarction; North America; Percutaneous Coronary Intervention; Prospective Studies; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome

Group-randomized trials of communities often rely on the convenience of pre-existing administrative divisions, such as school district boundaries or census entities, to divide the study area into intervention and control sites. However, these boundaries may include substantial heterogeneity between regions, introducing unmeasured confounding variables. This challenge can be addressed by the creation of exchangeable intervention and control territories that are equally weighted by pertinent socio-demographic characteristics. The present study used territory design software as a novel approach to partitioning study areas for The Minnesota Heart Health Program's "Ask about Aspirin" Initiative.. Twenty-four territories were created to be similar in terms of age, sex, and educational attainment, as factors known to modify aspirin use. To promote ease of intervention administration, the shape and spread of the territories were controlled. Means of the variables used in balancing the territories were assessed as well as other factors that were not used in the balancing process.. The analysis demonstrated that demographic characteristics did not differ significantly between the intervention and control territories created by the territory design software.. The creation of exchangeable territories diminishes geographically based impact on outcomes following community interventions in group-randomized trials. The method used to identify comparable geographical units may be applied to a wide range of population-based health intervention trials.. National Institutes of Health (Clinical Trials.gov), Identifier: NCT02607917 . Registered on 16 November 2015.

Topics: Aged; Aspirin; Cardiovascular Agents; Community Health Services; Cross-Over Studies; Female; Geographic Information Systems; Humans; Male; Middle Aged; Minnesota; Multicenter Studies as Topic; Myocardial Infarction; Patient Selection; Primary Prevention; Randomized Controlled Trials as Topic; Socioeconomic Factors; Software; Stroke

This study sought to measure early strut coverage in patients receiving drug-eluting stents (DESs) and to explore the feasibility of short-term dual antiplatelet therapy (DAPT) based on the degree of early strut coverage.. Data for early strut coverage in patients receiving new-generation DESs, and its implications for DAPT continuation were limited.. A randomized, multicenter trial was conducted in 894 patients treated with DESs. Patients were randomly assigned to everolimus-eluting stent (EES) (n = 444) or biolimus-eluting stent (BES) (n = 450) groups and optical coherence tomography (OCT)-guided (n = 445) or angiography-guided (n = 449) implantation groups using a 2-by-2 factorial design. Early strut coverage was measured as the percentage of uncovered struts on 3-month follow-up OCT examination. The primary outcome was the difference in early strut coverage between EES and BES groups and between OCT- and angiography-guided implantation groups. The secondary outcome was a composite of cardiac death, myocardial infarction, stent thrombosis, and major bleeding during the first 12 months post-procedure in patients receiving 3-month DAPT based on the presence of early strut coverage (≤6% uncovered) on 3-month follow-up OCT.. Three-month follow-up OCT data were acquired for 779 patients (87.1%). The median percentage of uncovered struts at 3 months was 8.9% and 8.2% in the EES and BES groups, respectively (p = 0.69) and was lower in the OCT-guided group (7.5%) than in the angiography-guided group (9.9%; p = 0.009). Favorable early strut coverage (≤6% uncovered strut) was observed in 320 of 779 patients (41.1%). At 12 months, the composite event rarely occurred in the 3-month (0.3%) or 12-month (0.2%) DAPT groups (p = 0.80).. OCT-guided DES implantation improved early strut coverage compared with angiography-guided DES implantation, with no difference in strut coverage between EES and BES groups. Short-term DAPT may be feasible in selected patients with favorable early strut coverage (Determination of the Duration of the Dual Antiplatelet Therapy by the Degree of the Coverage of The Struts on Optical Coherence Tomography From the Randomized Comparison Between Everolimus-eluting Stents Versus Biolimus A9-eluting Stents [DETECT-OCT]; NCT01752894).

Topics: Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Thrombosis; Drug Therapy, Combination; Drug-Eluting Stents; Everolimus; Feasibility Studies; Female; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Prosthesis Design; Republic of Korea; Risk Factors; Sirolimus; Stroke; Time Factors; Tomography, Optical Coherence; Treatment Outcome

This study sought to compare the clinical outcomes of 6-month versus 12-month dual antiplatelet therapy (DAPT) in patients receiving multiple biodegradable polymer-coated sirolimus-eluting stents (BP-SES) implants.. The clinical outcomes for patients who undergo multiple BP-SES implantation with different DAPT durations are uncertain.. In the I-LOVE-IT 2 trial, 907 patients treated with multiple BP-SES (total stent number ≥2) were assigned to receive 6-month (n = 440) or 12-month (n = 467) DAPT. The primary endpoint was 12-month target lesion failure (TLF), which is a composite of cardiac death, target vessel myocardial infarction (MI) or clinically indicated target lesion revascularization. The major secondary endpoints were 12-month net adverse clinical events, a composite of all causes of death, MI, stroke, any revascularization and bleeding.. The number of stents per patient between the 6-month and 12-month DAPT group was similar (2.4 ± 0.7 vs. 2.4 ± 0.7, P = 0.47). The incidence of 12-month TLF was comparable in the 6-month and 12-month DAPT groups (9.3% vs.7.5%, Log-rank P = 0.33). However, landmark analysis showed that 12-month DAPT, compared to 6-month DAPT, was associated with a significantly lower risk of TLF (4.8% vs. 2.4%, Log-rank P = 0.049) at a cost of a slightly increased risk of all bleeding events (0.5% vs. 1.7%, Log-rank P = 0.07) between 6 and 12 months.. In patients treated with multiple BP-SES, 6- and 12-month DAPT had similar impacts on 12-month clinical outcomes. Additionally, 12-month DAPT might reduce TLF between 6 and 12 months at the cost of a slightly increased risk of all bleeding events. © 2017 Wiley Periodicals, Inc.

Topics: Absorbable Implants; Acute Coronary Syndrome; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; China; Coronary Angiography; Coronary Artery Disease; Drug Administration Schedule; Drug Therapy, Combination; Drug-Eluting Stents; Female; Hemorrhage; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Polymers; Prospective Studies; Risk Factors; Sirolimus; Stroke; Time Factors; Treatment Outcome

Atherosclerosis is one of the main mechanisms of stroke and cardiovascular diseases and is associated with increased risk of recurrent stroke and cardiovascular events. Intima-medial thickness (IMT) is a well-known surrogate marker of atherosclerosis and has been used to predict stroke and cardiovascular events. However, the clinical significance of IMT and IMT change in stroke has not been investigated in well-designed studies. The PreventIon of CArdiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage-Intima-Media Thickness (PICASSO-IMT) sub-study is designed to investigate the effects of cilostazol, probucol, or both on IMT in patients with stroke.. PICASSO-IMT is a prospective sub-study of the PICASSO study designed to measure IMT and plaque score at 1, 13, 25, 37, and 49 months after randomization.. The primary outcome is the change in mean carotid IMT, which is defined as the mean of the far-wall IMTs of the right and left common carotid arteries, between baseline and 13 months after randomization.. PICASSO-IMT will provide the largest IMT data set in a stroke population and will provide valuable information about the clinical significance of IMT in patients with ischemic stroke.

Topics: Brain Ischemia; Cardiovascular Agents; Carotid Artery Diseases; Carotid Artery, Common; Carotid Intima-Media Thickness; Cerebral Hemorrhage; Cilostazol; Clinical Protocols; Double-Blind Method; Humans; Predictive Value of Tests; Probucol; Prospective Studies; Republic of Korea; Research Design; Risk Factors; Stroke; Tetrazoles; Time Factors; Treatment Outcome

Prior clinical trials produced evidence-based treatment recommendations for patients with asymptomatic carotid stenosis that may not be appropriate for clinical decision-making today. High-quality patient outcomes data to allow informed decision making regarding the optimal management of high-grade asymptomatic internal carotid artery stenosis is lacking. The results of the Asymptomatic Carotid Atherosclerosis Study were published in 1995 based on a randomized patient enrollment in the 1990s. Outcomes after endarterectomy, stenting, and medical treatment for these patients have all improved in the subsequent 2 decades. Therefore, the time has come to test whether contemporary intensive medical therapy is an acceptable alternative to contemporary endarterectomy or stenting and is the rationale for the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST-2) trial. This National Institute of Neurological Disorders and Stroke-sponsored prospective, multicenter clinical trial has the investigators, study teams, asymptomatic patients, and robust study design needed to provide these answers. Two randomized clinical trials are planned: carotid revascularization and intensive medical management versus medical management alone in patients with asymptomatic high-grade carotid stenosis randomize in a 1:1 ratio; the other trial will randomize patients in a 1:1 ratio to carotid stenting with embolic protection versus no stenting. ClinicalTrials.gov Identifier: NCT02089217.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Diffusion of Innovation; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Prospective Studies; Research Design; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome

Atrial fibrillation (AFib) is a common comorbidity in HF and affects patients' outcome. We sought to assess the effects of serelaxin in patients with and without AFib.. In a post hoc analysis of the RELAX-AHF trial, we compared the effects of serelaxin on efficacy end points, safety end points and biomarkers in 1161 patients with and without AFib on admission electrocardiogram.. AFib was present in 41.3% of patients. Serelaxin had a similar effect in patients with and without AFib, including dyspnea relief by visual analog scale through day 5 [mean change in area under the curve, 541.11 (33.79, 1048.44), p = 0.0366 in AFib versus 361.80 (-63.30, 786.90), p = 0.0953 in non-AFib, interaction p = 0.5954] and all-cause death through day 180 [HR = 0.42 (0.23, 0.77), p = 0.0051 in AFib versus 0.90 (0.53, 1.52), p = 0.6888 in non-AFib, interaction p = 0.0643]. Serelaxin was similarly safe in the two groups and induced similar reductions in biomarkers of cardiac, renal and hepatic damage. Stroke occurred more frequently in AFib patients (2.8 vs. 0.8%, p = 0.0116) and there was a trend for lower stroke incidence in the serelaxin arm in AFib patients (odds ratios, 0.31, p = 0.0759 versus 3.88, p = 0.2255 in non-AFib, interaction p = 0.0518).. Serelaxin was similarly safe and efficacious in improving short- and long-term outcomes and inducing organ protection in acute HF patients with and without AFib.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Biomarkers; Cardiovascular Agents; Dyspnea; Electrocardiography; Female; Heart Failure; Humans; Male; Middle Aged; Recombinant Proteins; Relaxin; Stroke; Treatment Outcome

In percutaneous coronary intervention (PCI) patients new-generation drug-eluting stent (DES) has reduced adverse events in comparison to early-generation DES. The aim of the current study was to investigate the long-term clinical efficacy and safety of new-generation DES versus early-generation DES for PCI of unprotected left main coronary artery (uLMCA) disease.. The patient-level data from the ISAR-LEFT MAIN and ISAR-LEFT MAIN 2 randomized trials were pooled. The clinical outcomes of PCI patients assigned to new-generation DES (everolimus- or zotarolimus-eluting stent) versus early-generation DES (paclitaxel- or sirolimus-eluting stent) were studied. The primary endpoint was the composite of death, myocardial infarction (MI), target lesion revascularization and stroke (MACCE, major adverse cardiac and cerebrovascular event).. In total, 1257 patients were available. At 3 years, the risk of MACCE was comparable between patients assigned to new-generation DES or early-generation DES (28.2 versus 27.5 %, hazard ratio-HR 1.03, 95 % confidence intervals-CI 0.83-1.26; P = 0.86). Definite/probable stent thrombosis was low and comparable between new-generation DES and early-generation DES (0.8 versus 1.6 %, HR 0.52, 95 % CI 0.18-1.57; P = 0.25); in patients treated with new-generation DES no cases occurred beyond 30 days. Diabetes increased the risk of MACCE in patients treated with new-generation DES but not with early-generation DES (P interaction = 0.004).. At 3-year follow-up, a PCI with new-generation DES for uLMCA disease shows comparable efficacy to early-generation DES. Rates of stent thrombosis were low in both groups. Diabetes significantly impacts the risk of MACCE at 3 years in patients treated with new-generation DES for uLMCA disease. ClinicalTrials.gov Identifiers: NCT00133237; NCT00598637.

Topics: Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Drug-Eluting Stents; Everolimus; Female; Germany; Humans; Italy; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Prosthesis Design; Risk Factors; Sirolimus; Stroke; Time Factors; Treatment Outcome

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris are frequent causes of hospital admission in the elderly. However, clinical trials targeting this population are scarce, and these patients are less likely to receive treatment according to guidelines. We aimed to investigate whether this population would benefit from an early invasive strategy versus a conservative strategy.. In this open-label randomised controlled multicentre trial, patients aged 80 years or older with NSTEMI or unstable angina admitted to 16 hospitals in the South-East Health Region of Norway were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment alone). A permuted block randomisation was generated by the Centre for Biostatistics and Epidemiology with stratification on the inclusion hospitals in opaque concealed envelopes, and sealed envelopes with consecutive inclusion numbers were made. The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death and was assessed between Dec 10, 2010, and Nov 18, 2014. An intention-to-treat analysis was used. This study is registered with ClinicalTrials.gov, number NCT01255540.. During a median follow-up of 1·53 years of participants recruited between Dec 10, 2010, and Feb 21, 2014, the primary outcome occurred in 93 (40·6%) of 229 patients assigned to the invasive group and 140 (61·4%) of 228 patients assigned to the conservative group (hazard ratio [HR] 0·53 [95% CI 0·41-0·69], p=0·0001). Five patients dropped out of the invasive group and one from the conservative group. HRs for the four components of the primary composite endpoint were 0·52 (0·35-0·76; p=0·0010) for myocardial infarction, 0·19 (0·07-0·52; p=0·0010) for the need for urgent revascularisation, 0·60 (0·25-1·46; p=0·2650) for stroke, and 0·89 (0·62-1·28; p=0·5340) for death from any cause. The invasive group had four (1·7%) major and 23 (10·0%) minor bleeding complications whereas the conservative group had four (1·8%) major and 16 (7·0%) minor bleeding complications.. In patients aged 80 years or more with NSTEMI or unstable angina, an invasive strategy is superior to a conservative strategy in the reduction of composite events. Efficacy of the invasive strategy was diluted with increasing age (after adjustment for creatinine and effect modification). The two strategies did not differ in terms of bleeding complications.. Norwegian Health Association (ExtraStiftelsen) and Inger and John Fredriksen Heart Foundation.

Topics: Aged, 80 and over; Angina, Unstable; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Female; Humans; Kaplan-Meier Estimate; Male; Myocardial Infarction; Myocardial Revascularization; Percutaneous Coronary Intervention; Postoperative Hemorrhage; Reoperation; Stroke; Time-to-Treatment; Treatment Outcome

This study has reported 10-year clinical follow-up of patients enrolled in the prospective, randomized LE MANS (Left Main Stenting) trial.. The very long-term outcome after left main stenting in comparison with surgical revascularization remains unknown.. In this prospective, multicenter trial, we randomly assigned 105 patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease according to SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score to percutaneous coronary intervention (PCI) with stenting (n = 52) or coronary artery bypass grafting (CABG) (n = 53). Drug-eluting stents were implanted in 35%, whereas arterial grafts to the left anterior descending artery were utilized in 81%. Currently, the mean long-term follow-up was collected at 9.8 ± 1.0 years. Follow up for all-cause mortality is complete, whereas the incidence of major adverse cardiovascular and cerebral events (MACCE) was reported from 90% of patients. Ambulatory follow-up was completed in 46 (43.9%) patients.. At 10 years, there was a trend toward higher ejection fraction in stenting when compared with surgery (54.9 ± 8.3% vs. 49.8 ± 10.3%; p = 0.07). The mortality (21.6% vs. 30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28) were statistically not different between groups; however, numerically the difference was in favor of stenting. Similarly, there was no difference in the occurrence of myocardial infarction (8.7 vs. 10.4%; p = 0.62), stroke (4.3 vs. 6.3%; p = 0.68), and repeated revascularization rates (26.1% vs. 31.3%; p = 0.64). The probability of very long-term survival up to 14 years was comparable between PCI and CABG (74.2% vs. 67.5%; p = 0.34; hazard ratio: 1.45, 95% confidence interval: 0.67 to 3.13); however, there was a trend toward higher MACCE-free survival in the PCI group (34.7% vs. 22.1%; p = 0.06; hazard ratio: 1.71, 95% confidence interval: 0.97 to 2.99).. In patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease, stenting offers numerically, but statistically nonsignificant, favorable long-term outcome up to 10 years in terms of safety and efficacy outcome measures, therefore, constitutes an alternative therapy for CABG.

Topics: Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Coronary Stenosis; Disease-Free Survival; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Risk Factors; Stents; Stroke; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Function, Left

Cardiac rehabilitation (CR) is the standard of care for patients with coronary heart disease. Despite considerable epidemiological evidence that high stress is associated with worse health outcomes, stress management training (SMT) is not included routinely as a component of CR.. One hundred fifty-one outpatients with coronary heart disease who were 36 to 84 years of age were randomized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT), with assessments of stress and coronary heart disease biomarkers obtained before and after treatment. A matched sample of CR-eligible patients who did not receive CR made up the no-CR comparison group. All participants were followed up for up to 5.3 years (median, 3.2 years) for clinical events. Patients randomized to CR+SMT exhibited greater reductions in composite stress levels compared with those randomized to CR alone (P=0.022), an effect that was driven primarily by improvements in anxiety, distress, and perceived stress. Both CR groups achieved significant, and comparable, improvements in coronary heart disease biomarkers. Participants in the CR+SMT group exhibited lower rates of clinical events compared with those in the CR-alone group (18% versus 33%; hazard ratio=0.49; 95% confidence interval, 0.25-0.95; P=0.035), and both CR groups had lower event rates compared with the no-CR group (47%; hazard ratio=0.44; 95% confidence interval, 0.27-0.71; P<0.001).. CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with standard CR. Our findings indicate that SMT may provide incremental benefit when combined with comprehensive CR and suggest that SMT should be incorporated routinely into CR.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00981253.

Topics: Aged; Angina, Unstable; Baroreflex; C-Reactive Protein; Cardiovascular Agents; Cognitive Behavioral Therapy; Combined Modality Therapy; Coronary Disease; Counseling; Exercise Test; Female; Humans; Lipids; Male; Middle Aged; Myocardial Infarction; Proportional Hazards Models; Psychological Tests; Psychometrics; Psychotherapy, Group; Single-Blind Method; Social Support; Stress, Psychological; Stroke; Vascular Surgical Procedures

The aim of this study was to investigate whether a 6-month dual-antiplatelet therapy (DAPT) duration was comparable with a 12-month duration in patients who underwent everolimus-eluting stent implantation.. Well-designed studies that determine optimal DAPT strategies after everolimus-eluting stent implantation are limited.. A total of 1,400 patients (implanted mean total stent length >45 mm) were randomly assigned to receive 6-month (n = 699) or 12-month (n = 701) DAPT between October 2010 and July 2014 at 20 centers in Korea. The primary endpoint was the composite of cardiac death, myocardial infarction, stroke, or TIMI (Thrombolysis in Myocardial Infarction) major bleeding at 1 year, analyzed using an intention-to-treat approach.. The primary endpoint occurred in 15 patients (2.2%) in the 6-month DAPT group and 14 patients (2.1%) in the 12-month DAPT group (hazard ratio [HR]: 1.07; p = 0.854). Definite or probable stent thrombosis occurred in 2 patients (0.3%) in the 6-month DAPT group and in 2 patients (0.3%) in the 12-month DAPT group (HR: 1.00; p = 0.999). There were no significant between-group differences in the primary endpoint in 686 patients with acute coronary syndrome (2.4% in both groups; HR: 1.00; p = 0.994) and in 506 patients with diabetes mellitus (2.2% [6-month] vs. 3.3% [12-month]; HR: 0.64; p = 0.428).. Compared with 12-month DAPT, 6-month DAPT did not increase the composite events of cardiac death, myocardial infarction, stroke, or TIMI major bleeding at 1 year in patients who underwent everolimus-eluting stent implantation. (Impact of Intravascular Ultrasound Guidance on Outcomes of XIENCE PRIME Stents in Long Lesions [IVUS-XPL Study]; NCT01308281).

Topics: Aspirin; Cardiovascular Agents; Clopidogrel; Coronary Thrombosis; Drug Administration Schedule; Drug Therapy, Combination; Drug-Eluting Stents; Everolimus; Hemorrhage; Humans; Intention to Treat Analysis; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Prosthesis Design; Republic of Korea; Risk Factors; Stroke; Ticlopidine; Time Factors; Treatment Outcome

Medication non-adherence is a major impediment to the management of cardiovascular disease risk factors. A better understanding of the modifying factors underlying medication non-adherence among individuals with known cardiovascular disease may inform approaches for addressing non-adherence.. The purpose of this study was to identify demographic and patient characteristics, medical comorbidities, psychosocial factors, and health belief-related factors associated with medication non-adherence among patients with known cardiovascular disease.. We performed secondary analysis of baseline data from a randomized trial.. The study included 405 patients with a diagnosis of hypertension and history of acute myocardial infarction that was diagnosed within a three-year period prior to enrollment.. Baseline demographics and patient characteristics, medical comorbidities, psychosocial factors, health belief-related factors, and patient-reported medication non-adherence were analyzed.. Of 405 patients, 173 (42.7 %) reported medication non-adherence. Factors associated with non-adherence in bivariate analysis included younger age, non-white race, having less than 12 years of education, smoking, financial insecurity, identifying as nervous or tense, higher life chaos score, greater worry about having a myocardial infarction, and greater worry about having a stroke. Using multivariable modeling, we determined that age (OR 0.97 per additional year, 95 % CI, 0.95-0.99), life chaos (OR 1.06 per additional point, 95 % CI, 1.00-1.11), and worry about stroke (OR 1.12 per additional point, 95 % CI, 1.01-1.25) remained significantly associated with self-reported medication non-adherence.. We found that worry about having a stroke, higher life chaos, and younger age were all significantly associated with self-reported medication non-adherence in patients with cardiovascular disease and a history of myocardial infarction. Further research exploring these factors as targets for intervention is needed, as is additional research examining modifiable causes of medication non-adherence among patients with cardiovascular disease.

Topics: Age Factors; Aged; Anxiety; Attitude to Health; Cardiovascular Agents; Comorbidity; Female; Humans; Hypertension; Life Style; Male; Medication Adherence; Middle Aged; Myocardial Infarction; Risk Factors; Self Administration; Self Report; Stroke

There is a paucity of data on the use of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting (CABG) and its long-term prognostic significance.. The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is a multicenter, randomized, clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with percutaneous coronary intervention or CABG. Detailed drug history was collected for all patients at discharge and at the 1-month, 6-month, 1-year, 3-year, and 5-year follow-ups. OMT was defined as the combination of at least 1 antiplatelet drug, statin, β-blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. OMT was underused in patients treated with coronary revascularization, especially CABG. OMT was an independent predictor of survival. OMT was associated with a significant reduction in mortality (hazard ratio, 0.64; 95% confidence interval, 0.48-0.85; P=0.002) and composite end point of death/myocardial infarction/stroke (hazard ratio, 0.73; 95% confidence interval, 0.58-0.92; P=0.007) at the 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5 years) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus percutaneous coronary intervention over 5 years). On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy.. The use of OMT remains low in patients with complex coronary disease requiring coronary intervention with percutaneous coronary intervention and even lower in patients treated with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT use in postrevascularization patients are warranted.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.

Topics: Aged; Biomarkers; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass; Coronary Disease; Drug Utilization; Drug-Eluting Stents; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Netherlands; Paclitaxel; Percutaneous Coronary Intervention; Prognosis; Proportional Hazards Models; Prospective Studies; Risk Factors; Stroke; Treatment Outcome

Danhong injection (DHI) has been widely prescribed to patients with acute ischemic stroke (AIS). However, due to methodological deficiencies, previous research has not yet provided rigorous evidence to support the use of DHI in the treatment of AIS. Therefore, we designed this multicenter, randomized, controlled, and double-blind trial to evaluate the efficacy and safety of DHI for AIS.. It is a randomized, multicenter, double-blind, placebo-controlled, adaptive clinical trial. A total of 864 eligible patients will be randomized into either the DHI or placebo group in a 2:1 ratio. All patients will be given the standard medical care as recommended by guidelines. Participants will undergo a 2-week treatment regimen and 76-day follow-up period. The primary outcome is the proportion of patients with a favorable outcome, defined as a score of 0-1 on the modified Rankin scale at day 90. Secondary outcomes include a change in the total score of the Chinese medicine symptom scales of "Xueyu Zheng" (blood stasis syndrome), the proportion of patients with a Barthel Index score of ≥90, the proportion of patients with an improvement in NIHSS score of ≥4 or NIHSS score of 0-1, quality of life measured by the EQ-5D scale, etc. Safety outcomes such as global disability (mRS ≥3) at day 90 will also be assessed. The changes in mRNA and microRNA profiles in 96 patients selected from certain centers will also be assessed. As this is an adaptive design, two interim analyses are prospectively planned, which will be carried out after one-third and two-thirds of patients have completed the trial, respectively. Based on the results of the interim analyses, the Data Monitoring Committee (DMC) will decide how to modify the study.. This trial will provide high-quality evidence for DHI in treatment of AIS.. Clinical Trials.gov NCT01677208 (Date of registration 22 December 2012).

Topics: Adolescent; Adult; Aged; Brain Ischemia; Cardiovascular Agents; China; Clinical Protocols; Disability Evaluation; Double-Blind Method; Drugs, Chinese Herbal; Female; Gene Expression Profiling; Genetic Markers; Humans; Injections; Male; MicroRNAs; Middle Aged; Quality of Life; Research Design; RNA, Messenger; Stroke; Surveys and Questionnaires; Time Factors; Treatment Outcome; Young Adult

Good communication between hospital and primary care physicians (PCPs) is important for the continuity of patient care in the transition phase following hospital treatment. Drug-related problems and medication errors may occur at that interface. Discharge letters often lack a structured medication report at the end and therefore may not provide the reasons for medication changes, resulting in low adherence rates. The objectives were to develop a structured medication report as part of the discharge letter, to evaluate the impact of the medication report in ischaemic stroke patients and to identify the most important issues in the transitional care process of stroke patients.. First, a structured medication report was developed. Thereafter, the impact of this new medication report on clinical practice was evaluated with an open, prospective, interventional two-phase study conducted at the Klinikum Fulda gAG (Germany), which included patients with ischaemic stroke and >2 drugs in the discharge medication. In the control group (CG), the neurologist included the current medication in the discharge letter. In the intervention group (IG), the clinical pharmacist added the detailed information to a medication report. To evaluate adherence to discharge medication, the PCP was interviewed 3 months after hospital discharge about the medication. Adherence was measured with respect to the entire medication regimen, antithrombotic and cholesterol-lowering drugs and discontinued medication. The most important issues in the transitional care for patients with ischaemic stroke were identified on the basis of the secondary stroke prevention and cardiovascular risk factors.. Overall, 312 patients were enrolled in the study with 156 patients in each group. By providing detailed information in the newly developed discharge letter, adherence increased significantly from 83·3% (CG) to 90·9% (IG; P = 0·01). Significant differences between the CG and IG were found with regard to adherence to both antithrombotic drugs [83·8% CG vs. 91·9% IG (P = 0·033)] and statin therapy [69·8% CG vs. 87·7% IG (P < 0·001)].. The use of a structured medication report as part of the discharge letter leads to improved adherence to hospital discharge medication.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Continuity of Patient Care; Female; Humans; Male; Medication Adherence; Medication Reconciliation; Middle Aged; Patient Discharge; Prospective Studies; Risk Factors; Stroke

The study objective was to identify the predictors of outcomes in a contemporary cohort of patients from the Reduction in cardiovascular Events by acaDesine in patients undergoing CABG (RED-CABG) trial. Despite the increasing risk profile of patients who undergo coronary artery bypass grafting, morbidity and mortality have remained low, and identification of the current predictors of adverse outcomes may permit new treatments to further improve outcomes.. The RED-CABG trial was a multicenter, randomized, double-blind, placebo-controlled study that determined that acadesine did not reduce adverse events in moderately high-risk patients undergoing nonemergency coronary artery bypass grafting. The primary efficacy end point was a composite of all-cause death, nonfatal stroke, or the need for mechanical support for severe left ventricular dysfunction through postoperative day 28. Logistic regression modeling with stepwise variable selection identified which prespecified baseline characteristics were associated with the primary outcome. A second logistic model included intraoperative variables as potential covariates.. The 4 independent preoperative risk factors predictive of the composite end point were (1) a history of heart failure (odds ratio, 2.9); (2) increasing age (odds ratio, 1.033 per decade); (3) a history of peripheral vascular disease (odds ratio, 1.6); and (4) receiving aspirin before coronary artery bypass grafting (odds ratio, 0.5), which was protective. The duration of the cardiopulmonary bypass (odds ratio, 1.8) was the only intraoperative variable that contributed to adverse outcomes.. Patients who had heart failure and preserved systolic function had a similar high risk of adverse outcomes as those with low ejection fractions, and new approaches may mitigate this risk. Recognition of patients with excessive atherosclerotic burden may permit perioperative interventions to improve their outcomes. The contemporary risks of coronary artery bypass grafting have changed, and their identification may permit new methods to improve outcomes.

Topics: Age Factors; Aminoimidazole Carboxamide; Aspirin; Cardiopulmonary Bypass; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Bypass; Double-Blind Method; Heart Failure; Humans; Logistic Models; Multivariate Analysis; Odds Ratio; Patient Selection; Peripheral Arterial Disease; Protective Factors; Ribonucleosides; Risk Assessment; Risk Factors; Stroke; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left

The aim of this study was to evaluate the efficacy of a long-term secondary prevention programme following inpatient cardiovascular rehabilitation on cardiovascular risk and health-related quality of life in a cohort of middle-aged (≤58 years) coronary artery disease (CAD) patients of low educational level compared to usual care.. The study included 600 patients with CAD, with 271 in the intervention group (IG) and 329 in the control group (CG). The average age was nearly 50 years in both groups, nearly 90% were male, and 77% had less than 10 years of school education. No significant differences existed between the groups at baseline. Both groups had a 3-week comprehensive cardiovascular inpatient rehabilitation programme at the beginning, the intervention consisted of one further rehabilitation session in hospital after 6 months and regular telephone reminders over a period of 36 months. Analyses were conducted on an intention-to-treat basis. To evaluate the individual risk level, we used the PROCAM score and intima-media thickness (IMT) was measured at the common carotid artery on both sides following international standards. Health-related quality of life was assessed with the EUROQOL and HADS.. Patients in the IG showed better 3-year risk profile outcomes. The PROCAM score increased by 3.0 (IG) and by 3.7 (CG) from the beginning to after 3 years (p > 0.05 intention-to-treat). The average IMT increased by 0.04 mm in the CG and was reduced by 0.03 mm in the IG (p = 0.014 for the difference). The IG had a significant improvement in health-related quality of life. Mortality, myocardial infarction, and stroke were not different although 'other cardiac events' (cardiac surgery or intervention) were significantly lower in the IG than the CG patients (p < 0.05).. This long-term secondary prevention programme with inpatient rehabilitation at the beginning and telephone reminder for a 3-year period was successful. There were significant differences in health-related quality of life between the IG and CG, despite the relatively positive outcomes in the CG. In this low-education (predominantly male), middle-aged cohort, the positive impact on cardiovascular risk was pronounced in the high-risk subgroup (PROCAM 10-year risk 10-40%).

Topics: Adult; Cardiovascular Agents; Carotid Artery, Common; Carotid Intima-Media Thickness; Combined Modality Therapy; Coronary Artery Disease; Educational Status; Exercise Therapy; Female; Germany; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Myocardial Infarction; Patient Education as Topic; Prospective Studies; Quality of Life; Reminder Systems; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Surveys and Questionnaires; Telephone; Time Factors; Treatment Outcome

To investigate the predictive values of placental growth factor (PlGF) and its endogenous antagonist, soluble fms-like tyrosine kinase-1 (sFlt-1), for the long-term prognosis of patients with stable coronary artery disease (CAD). Both PlGF and sFlt-1 play important roles in the pathological mechanisms of atherosclerosis. We recently demonstrated that the plasma levels of these molecules are correlated with the severity of coronary atherosclerosis.. We enrolled 464 patients with stable CAD who consecutively underwent coronary angiography. Baseline blood samples were collected from the femoral artery immediately before coronary angiography (after the administration of 20 units of heparin), and the plasma levels of PlGF and sFlt-1 were measured. A Cox proportional hazard regression analysis was performed to evaluate the relationship between these parameters and the occurrence of all-cause death (ACD) and total cardiovascular events (TCVE) during a median follow-up of 3.3 years.. A total of 31 ACDs and 51 TCVEs occurred. Patients with higher PlGF/sFlt-1 ratios (>4.22×10(-2)) had a significantly higher risk of both ACD and TCVE than patients with lower ratios (<4.22×10(-2)) (hazard ratio [HR]: 3.32, 95% confidence interval [CI]: 1.43 to 7.72, p=0.005, and HR: 2.23, 95% CI: 1.23 to 4.03, p=0.008, respectively). A multivariate analysis showed the PlGF/sFlt-1 ratio to be an independent predictor for ACD, but not TCVE.. The baseline PlGF/sFlt-1 ratio is an independent predictor of long-term adverse outcomes in patients with stable CAD.

Topics: Aged; Biomarkers; Cardiovascular Agents; Cause of Death; Comorbidity; Coronary Angiography; Coronary Artery Disease; Female; Follow-Up Studies; Heart Failure; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Placenta Growth Factor; Plasma; Pregnancy Proteins; Prognosis; Proportional Hazards Models; Risk Factors; Stroke; Treatment Outcome; Vascular Endothelial Growth Factor Receptor-1

The aim of this study was to determine the impact of mean platelet volume (MPV) on the strategy for treatment of atrial fibrillation (AF) with respect to stroke prevention. MPV was analyzed in 265 patients with AF who were undergoing treatment using rhythm or rate control. The primary endpoint was ischemic stroke or a transient ischemic attack (TIA) event. Kaplan-Meier analysis revealed a significantly higher stroke rate in the rate control group compared to the rhythm control group. A significantly higher stroke rate was observed in the higher tertile MPV group (≥7.9 fL) compared to the lower tertile MPV group (<7.3 fL). When the MPV cut-off level was set to 7.85 fL using the receiver operating characteristic curve, the sensitivity was 80.0% and the specificity was 70.4% for differentiating between the group with stroke and the group without stroke. In the Cox proportional hazard analysis, after adjusting for sex, treatment strategy for AF, high MPV level, antithrombotic treatment, and high CHADS2 score, higher MPV, rate control strategy for treatment of AF, and high CHADS2 score were found to be independent predictors of stroke risk. In addition, patients with AF who were treated using rate control had high stroke risk with an MPV over 7.85 fL and high CHADS2 score. The results of this study demonstrate that the MPV and the rate control strategy for treatment of AF were predictive markers for stroke; its predictive power for stroke was independent of female sex and high CHADS2 score in patients with AF.

Topics: Aged; Anti-Arrhythmia Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Mean Platelet Volume; Middle Aged; Predictive Value of Tests; Proportional Hazards Models; ROC Curve; Sensitivity and Specificity; Stroke; Treatment Outcome

Assuming that coronary interventions, both coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI), are directed to preserve left ventricular function, it is not known whether medical therapy alone (MT) can achieve this protection. Thus, we evaluated the evolution of LV ejection fraction (LVEF) in patients with stable coronary artery disease (CAD) treated by CABG, PCI, or MT as a post hoc analysis of a randomized controlled trial with a follow-up of 10 years.. Left ventricle ejection fraction was assessed with transthoracic echocardiography in patients with multivessel CAD, participants of the MASS II trial before randomization to CABG, PCI, or MT, and re-evaluated after 10 years of follow-up.. Of the 611 patients, 422 were alive after 10.32 ± 1.43 years. Three hundred and fifty had LVEF reassessed: 108 patients from MT, 111 from CABG, and 131 from PCI. There was no difference in LVEF at the beginning (0.61 ± 0.07, 0.61 ± 0.08, 0.61 ± 0.09, respectively, for PCI, CABG, and MT, P = 0.675) or at the end of follow-up (0.56 ± 0.11, 0.55 ± 0.11, 0.55 ± 0.12, P = 0.675), or in the decline of LVEF (reduction delta of -7.2 ± 17.13, -9.08 ± 18.77, and -7.54 ± 22.74). Acute myocardial infarction (AMI) during the follow-up was associated with greater reduction in LVEF. The presence of previous AMI (OR: 2.50, 95% CI: 1.40-4.45; P = 0.0007) and during the follow-up (OR: 2.73, 95% CI: 1.25-5.92; P = 0.005) was associated with development of LVEF <45%.. Regardless of the therapeutic option applied, LVEF remains preserved in the absence of a major adverse cardiac event after 10 years of follow-up.. http://www.controlled-trials.com. Registration number ISRCTN66068876.

Topics: Aged; Analysis of Variance; Cardiovascular Agents; Coronary Artery Bypass; Coronary Stenosis; Echocardiography; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Percutaneous Coronary Intervention; Stroke; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left

Mildronate, an inhibitor of carnitine-dependent metabolism, is considered to be an anti-ischemic drug. This study is designed to evaluate the efficacy and safety of mildronate injection in treating acute ischemic stroke.. We performed a randomized, double-blind, multicenter clinical study of mildronate injection for treating acute cerebral infarction. 113 patients in the experimental group received mildronate injection, and 114 patients in the active-control group received cinepazide injection. In addition, both groups were given aspirin as a basic treatment. Modified Rankin Scale (mRS) score was performed at 2 weeks and 3 months after treatment. National Institutes of Health Stroke Scale (NIHSS) score and Barthel Index (BI) score were performed at 2 weeks after treatment, and then vital signs and adverse events were evaluated.. A total of 227 patients were randomized to treatment (n = 113, mildronate; n = 114, active-control). After 3 months, there was no significant difference for the primary endpoint between groups categorized in terms of mRS scores of 0-1 and 0-2 (p = 0.52 and p = 0.07, respectively). There were also no significant differences for the secondary endpoint between groups categorized in terms of NIHSS scores of >5 and >8 (p = 0.98 and p = 0.97, respectively) or BI scores of >75 and >95 (p = 0.49 and p = 0.47, respectively) at 15 days. The incidence of serious adverse events was similar between the two groups.. Mildronate injection is as effective and safe as cinepazide injection in treating acute cerebral infarction.

Topics: Aged; Brain Ischemia; Cardiovascular Agents; Double-Blind Method; Female; Humans; Male; Methylhydrazines; Middle Aged; Stroke; Treatment Outcome

ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization.. Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012.. A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%.. Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions.. ISRCTN21144362.

Topics: Aged; Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Male; Middle Aged; Myocardial Infarction; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome

This study sought to investigate the impact of left main coronary artery (LMCA) 3-dimensional (3D) bifurcation angle (BA) parameters on 5-year clinical outcomes of patients randomized to LMCA percutaneous coronary intervention (PCI) in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial.. BA can affect outcome after bifurcation PCI; 3D angiographic analysis provides reliable BA measurements.. The diastolic distal BA (between left anterior descending and left circumflex) and its systolic-diastolic range were explored. A stratified post-hoc survival analysis was performed for 5-year major adverse cardiac and cardiovascular events (MACCE) (all-cause death, cerebrovascular accident, myocardial infarction, or repeat revascularization), a safety endpoint (all-cause death, cerebrovascular accident, or myocardial infarction), and repeat revascularization. Analysis was performed in patients where 3D BA was available pre- and post-PCI.. Of 266 patients eligible for analysis, 185 underwent bifurcation PCI (group B); 1 stent was used in 75 patients (group B1), whereas ≥2 stents were used in 110 patients (group B2). Stratification across pre-PCI diastolic distal BA tertiles (<82°, 82° to 106°, ≥107°) failed to show any difference in MACCE rates either in the entire study population (p = 0.99) or in group B patients (p = 0.78). Group B patients with post-PCI systolic-diastolic range <10° had significantly higher MACCE rates (50.8% vs. 22.7%, p < 0.001); repeat revascularization and safety endpoint rates were also higher (37.4% vs. 15.5%, p = 0.002, and 25.4% vs. 14.1%, p=0.055, respectively). Post-PCI systolic-diastolic range <10° was an independent predictor of MACCE (hazard ratio: 2.65; 95% confidence interval: 1.55 to 4.52; p < 0.001) in group B patients.. A restricted post-procedural systolic-diastolic distal BA range resulted in higher 5-year adverse event rates after LMCA bifurcation PCI. Pre-PCI BA value did not affect the clinical outcome.

Topics: Aged; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Coronary Thrombosis; Coronary Vessels; Drug-Eluting Stents; Humans; Imaging, Three-Dimensional; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Paclitaxel; Percutaneous Coronary Intervention; Predictive Value of Tests; Proportional Hazards Models; Prospective Studies; Radiographic Image Interpretation, Computer-Assisted; Risk Factors; Stroke; Time Factors; Treatment Outcome

To assess the impact of age on safety and efficacy of paclitaxel-eluting stent (PES) implantation during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).. The benefits of paclitaxel-eluting stent (PES) implantation during primary PCI were confirmed by the long-term results of the HORIZONS-AMI trial. Whether the effects of PES are independent of age has not been reported.. Data on 3,006 patients from the HORIZONS-AMI study randomized in a 3:1 ratio to PES or bare-metal stent (BMS) in whom at least one stent was implanted were assessed. There were 2,302 (76.6%) patients <70, and 704 patients ≥70 years of age.. At 3 years, among older patients a trend toward lower risk of major adverse cardiac events (MACE; death from any cause, stroke, reinfarction and unplanned revascularization for ischemia) related to PES use was observed (PES vs. BMS: 18.0% vs. 21.3%; P = 0.07). There was also a trend for reduction of MACE related to PES in older patients (26.4% vs. 33.1%; P = 0.09). Both, patients <70 and ≥70 years of age treated with PES were at lower risk for ischemic target vessel revascularization. However, a higher risk of major bleeding in elderly patients treated with PES was observed (P = 0.02 for interaction between age group and PES effects). No interaction between age and stent type in terms of the risk of other clinical end points, including all-cause death, was confirmed.. For STEMI patients undergoing primary PCI, the implantation of PES as compared with BMS reduced ischemic TVR, and this effect was independent of age.

Topics: Age Factors; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Disease-Free Survival; Drug-Eluting Stents; Female; Hemorrhage; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Paclitaxel; Recurrence; Risk Factors; Stroke; Time Factors; Treatment Outcome

The Oral Rapamycin in ARgentina (ORAR) III trial is a randomized study comparing a strategy of oral rapamycin (OR) plus bare-metal stent (BMS) versus a strategy of drug-eluting stents (DES) in patients with de novo coronary lesions. The purpose of this study was to assess the 3 years cost-effectiveness outcome of each strategy.. OR after BMS has been associated with reduction of target vessel revascularization (TVR) although its value in long-term efficacy in comparison with DES is unknown.. In three hospitals in Buenos Aires, Argentina, 200 patients were randomized to OR plus BMS (n = 100) or DES (n = 100). Primary objectives were costs and effectiveness. Cost analysis included in-hospital and follow-up costs. Safety was defined as the composite of death, myocardial infarction (MI), and stroke. Efficacy was defined as TVR.. Baseline characteristics between groups were similar. The 3-year follow-up rate was 99%. Cardiac mortality was 2% and 5% in OR group and DES group, respectively (P = 0.44). The composite of death, MI and stroke rate was 11% in OR group and 20% in DES group (P = 0.078). TVR rate was 14.5% in OR group and 17.6% in DES group (P = 0.50), respectively. Three year cumulative costs were significantly lower in the OR arm as compared to the DES arm (P = 0.0001) and DES strategy did not result cost-effective according to the non-inferiority test.. At 3 years follow-up, there were no differences in effectiveness between the two strategies, and DES strategy was not more cost-effective as compared to OR plus BMS.

Topics: Administration, Oral; Aged; Argentina; Cardiovascular Agents; Chi-Square Distribution; Combined Modality Therapy; Coronary Artery Disease; Coronary Restenosis; Cost Savings; Cost-Benefit Analysis; Drug Costs; Drug-Eluting Stents; Female; Health Care Costs; Hospital Costs; Humans; Kaplan-Meier Estimate; Male; Metals; Middle Aged; Multivariate Analysis; Myocardial Infarction; Percutaneous Coronary Intervention; Proportional Hazards Models; Prosthesis Design; Risk Assessment; Risk Factors; Sirolimus; Stents; Stroke; Time Factors; Treatment Outcome

Recent secondary prevention trials have failed to demonstrate a beneficial effect of n-3 fatty acids on cardiovascular outcomes, which may be due to the growing use of statins since the mid-1990s. The aim of the present study was to assess whether statins modify the effects of n-3 fatty acids on major adverse cardiovascular events in patients with a history of myocardial infarction (MI).. Patients who participated in the Alpha Omega Trial were divided into consistent statin users (n = 3740) and consistent statin non-users (n = 413). In these two groups of patients, the effects of an additional daily amount of 400 mg eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA), 2 g α-linolenic acid (ALA), or both on major cardiovascular events were evaluated. Multivariable Cox's proportional hazard models were used to calculate adjusted hazard rate ratios (HR(adj)). Among the statin users 495 (13%) and among the statin non-users 62 (15%) developed a major cardiovascular event. In statin users, an additional amount of n-3 fatty acids did not reduce cardiovascular events [HR(adj) 1.02; 95% confidence interval (CI): 0.80, 1.31; P = 0.88]. In statin non-users, however, only 9% of those who received EPA-DHA plus ALA experienced an event compared with 18% in the placebo group (HR(adj) 0.46; 95% CI: 0.21, 1.01; P= 0.051).. In patients with a history of MI who are not treated with statins, low-dose supplementation with n-3 fatty acids may reduce major cardiovascular events. This study suggests that statin treatment modifies the effects of n-3 fatty acids on the incidence of major cardiovascular events.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Dietary Supplements; Double-Blind Method; Drug Interactions; Fatty Acids, Omega-3; Female; Heart Arrest; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Lipid Metabolism; Male; Margarine; Middle Aged; Myocardial Infarction; Stroke

Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70 ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During a mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)). No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Disease Progression; Female; Glomerular Filtration Rate; Guideline Adherence; Humans; Kidney; Kidney Failure, Chronic; Linear Models; Male; Middle Aged; Motor Activity; Myocardial Infarction; Netherlands; Nurse Practitioners; Practice Guidelines as Topic; Preventive Health Services; Proportional Hazards Models; Renal Insufficiency, Chronic; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Smoking Cessation; Stroke; Time Factors; Treatment Outcome; Weight Loss

Topics: Angioplasty, Balloon; Cardiovascular Agents; Combined Modality Therapy; Constriction, Pathologic; Humans; Intracranial Arteriosclerosis; Research Design; Risk Assessment; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Stents; Stroke; Treatment Outcome

This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS).. Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.. A total of 313 patients ≥ 75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.. During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03).. The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185).

Topics: Acute Coronary Syndrome; Age Factors; Aged; Aged, 80 and over; Biomarkers; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Female; Humans; Italy; Kaplan-Meier Estimate; Male; Myocardial Infarction; Patient Readmission; Percutaneous Coronary Intervention; Postoperative Hemorrhage; Proportional Hazards Models; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome; Troponin; Up-Regulation

The aim of this study was to compare the 5-year outcomes of patients with multivessel disease (MVD) involving the proximal left anterior descending (LAD) artery who were treated with sirolimus drug-eluting stents (SES), bare metal stents (BMS) and coronary artery bypass surgery (CABG).. Clinical outcomes were compared between the 682 patients enrolled in the ARTS-I and ARTS-II study who had MVD involving the proximal LAD, and were treated with BMS (27.4%), CABG (30.2%), and SES (42.4%). At 5-year follow-up the primary endpoint of major adverse cardiovascular and cerebrovascular events (MACCE) occurred in 33.7%, 18.0% and 24.9% of patients treated with BMS, CABG and SES, respectively (BMS vs. SES p=0.04, CABG vs. SES p=0.07). Unadjusted and adjusted rates of mortality and death/stroke/myocardial infarction (safety) were comparable between all three treatments. Repeat revascularisation was significantly lower following CABG irrespective of adjustment. The absolute difference in MACCE between patients with a logistic EuroSCORE above and below the mean (i.e., 2.09%) was 18.8% (p=0.001), and 1.9% (p=0.28) for CABG and SES, respectively. In patients with a high EuroSCORE, SES was a significantly safer treatment (p=0.04) whilst repeat revascularisation remained lower with CABG irrespective of the EuroSCORE.. At 5-year follow-up CABG has comparable safety, and superior efficacy in terms of reducing repeat revascularisation compared to BMS and SES in the treatment of patients with MVD involving the proximal LAD however, appropriate patient selection remains imperative.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Drug-Eluting Stents; Female; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Metals; Middle Aged; Myocardial Infarction; Netherlands; Patient Selection; Proportional Hazards Models; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Sirolimus; Stents; Stroke; Thrombosis; Time Factors; Treatment Outcome

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion.. From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months.. There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B.. Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Topics: Aged; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Chi-Square Distribution; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Patient Selection; Prospective Studies; Recurrence; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Our aim was to access clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in older patients with stable coronary artery disease (CAD).. While older patients with CAD are at increased risk for cardiac events compared with younger patients, it is unclear whether PCI may mitigate this risk more effectively than OMT alone or, alternatively, may be associated with more complications.. We conducted a pre-specified analysis of outcomes in stable CAD patients stratified by age and randomized to PCI+OMT or OMT alone in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial.. A total of 1,381 patients (60%) were <65 years of age (mean 56+/-6 years) and 904 patients (40%) were >or=65 years of age (mean 72+/-5 years). Achieved treatment targets for blood pressure, low-density lipoprotein cholesterol, adherence to diet and exercise, and angina-free status did not differ by age or treatment assignment. Among older patients, there was a 2- to 3-fold higher death rate, but similar rates of myocardial infarction, stroke, and major cardiac events compared with younger patients. The addition of PCI to OMT did not improve or worsen clinical outcomes in patients>or=65 years of age during a median 4.6 year follow-up.. These data support adherence to American College of Cardiology/American Heart Association clinical practice guidelines that advocate OMT as an appropriate initial management strategy, regardless of age. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).

Topics: Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Blood Pressure; Body Mass Index; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Disease; Diet; Exercise; Female; Follow-Up Studies; Hospitalization; Humans; Lipoproteins, LDL; Male; Myocardial Infarction; Outcome Assessment, Health Care; Smoking Cessation; Stroke

Previous randomised studies have shown a significant reduction in restenosis when oral rapamycin (OR) is administered to patients undergoing bare metal stent (BMS) implantation. How this regimen compares to drug eluting stents (DES) is unknown.. Two-hundred patients with de novo coronary lesions were randomised to treatment with OR plus BMS (100 pts) or with DES (100 pts). OR was given as a bolus of 10 mg per day before PCI followed by daily doses of 3 mg during following 13 days. Primary endpoints were to compare hospital, follow-up and overall cost at one, two, three and five years of follow-up. The secondary endpoints included death, myocardial infarction (MI) and stroke and were analysed as major adverse cardiovascular events (MACCE). Target vessel (TVR) and target lesion revascularisation (TLR) were independently analysed. Costs included procedural resources, hospitalisation, medications, repeat revascularisation procedures and professional fees. Baseline demographic, clinical and angiographic characteristics were similar. At 18.3 +/- 7 months of follow-up, the initial strategy of OR plus BMS resulted in significant cost saving when compared to DES (p=0.0001). TLR rate was 8.2% with DES and 7.0% with OR plus BMS (p=0.84), similarly no differences in TVR rate in both groups was seen (10.6% and 10.5% in OR and DES group respectively, p=0.86). Non-inferiority testing, determined that DES therapy failed to be cost saving compared to OR in all possible cost scenarios.. A strategy of OR plus BMS is cost saving compared to DES in patients undergoing PCI for de novo coronary lesions.

Topics: Administration, Oral; Aged; Angioplasty, Balloon, Coronary; Argentina; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Restenosis; Cost Savings; Drug-Eluting Stents; Female; Health Care Costs; Hospital Mortality; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Metals; Middle Aged; Myocardial Infarction; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Risk Assessment; Sirolimus; Stents; Stroke; Time Factors; Treatment Outcome

Diabetes is an important risk factor for stroke. We conducted analyses in patients who had entered the PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive) with a history of stroke or without stroke.. The prospective, double-blind PROactive (mean duration, 34.5 months) randomized 5238 patients with type 2 diabetes and a history of macrovascular disease to pioglitazone (titrated to 45 mg) or placebo, in addition to current diabetes and cardiovascular medications. Cardiovascular end-point events were independently adjudicated. This analysis evaluated the risk of stroke and other cardiovascular outcomes in patients with (n=984) and without (n=4254) prior stroke.. In patients with previous stroke (n=486 in the pioglitazone group and n=498 in the placebo group), there was a trend of benefit with pioglitazone for the primary end point of all-cause death, nonfatal myocardial infarction, acute coronary syndrome, and cardiac intervention (including coronary artery bypass graft or percutaneous coronary intervention), stroke, major leg amputation, or bypass surgery or leg revascularization (hazard ratio[HR]=0.78, event rate=20.2% pioglitazone vs 25.3% placebo; 95% CI=0.60-1.02; P=0.0670) and for the main secondary end point of all-cause death, nonfatal myocardial infarction, or nonfatal stroke (HR=0.78, event rate=15.6% pioglitazone vs 19.7% placebo; 95% CI=0.58-1.06; P=0.1095). Pioglitazone reduced fatal or nonfatal stroke (HR=0.53, event rate=5.6% pioglitazone vs 10.2% placebo; 95% CI=0.34-0.85; P=0.0085) and cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke (HR=0.72, event rate=13.0% pioglitazone vs 17.7% placebo; 95% CI=0.52-1.00; P=0.0467). Higher event rates were observed in patients with prior stroke compared with those without prior stroke. In patients without prior stroke, no treatment effect was observed for a first stroke.. In a subgroup analysis from PROactive, pioglitazone reduced the risk of recurrent stroke significantly in high-risk patients with type 2 diabetes.

Topics: Adult; Aged; Cardiovascular Agents; Diabetes Mellitus, Type 2; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Pioglitazone; Prospective Studies; Stroke; Thiazolidinediones; Vascular Diseases

The free-radical-trapping agent NXY-059 showed promise as a neuroprotectant in the Stroke-Acute Ischemic NXY Treatment I (SAINT I) trial, reducing disability when given to patients who had acute ischemic stroke. We sought confirmation of efficacy in a second, larger trial.. We enrolled 3306 patients with acute ischemic stroke in a randomized, double-blind trial to receive a 72-hour infusion of intravenous NXY-059 or placebo within 6 hours after the onset of stroke symptoms. Our primary end point was the distribution of disability scores on the modified Rankin scale at 90 days. We examined scores on neurologic and activities-of-daily-living scales as secondary end points. We also tested the hypothesis that NXY-059 would reduce alteplase-related intracranial hemorrhages.. The efficacy analysis was based on 3195 patients. Prognostic factors were well balanced between the treatment groups. Mortality was equal in the two groups, and adverse-event rates were similar. The distribution of scores on the modified Rankin scale did not differ between the group treated with NXY-059 (1588 patients) and the placebo group (1607 patients; P=0.33 by the Cochran-Mantel-Haenszel test; odds ratio for limiting disability, 0.94; 95% confidence interval [CI], 0.83 to 1.06). Analysis of categorized scores on the modified Rankin scale confirmed the lack of benefit: the odds ratio for trichotomization into modified Rankin scale scores of 0 to 1 versus 2 to 3 versus 4 to 6 was 0.92 (95% CI, 0.80 to 1.06). There was no evidence of efficacy for any of the secondary end points. Among patients treated with alteplase, there was no difference between the NXY-059 group and the placebo group in the frequency of symptomatic or asymptomatic hemorrhage.. NXY-059 is ineffective for the treatment of acute ischemic stroke within 6 hours after the onset of symptoms. (ClinicalTrials.gov number, NCT00061022 [ClinicalTrials.gov].)

Topics: Acute Disease; Aged; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Double-Blind Method; Female; Humans; Infusions, Intravenous; Male; Odds Ratio; Stroke; Time Factors; Treatment Failure

Left ventricular assist device (LVAD) failure and malfunction rates are critical gauges for establishing LVADs as a long-term therapy for end-stage heart failure patients. These device performance measures, however, have been inadequately characterized in the bridge-to-transplantation literature.. REMATCH is a randomized trial that compares optimal medical management with LVAD implantation for patients with end-stage heart failure. An independent committee adjudicated patient outcomes. The primary endpoint--survival--was analyzed by intention to treat using the log-rank statistic. Frequency of event occurrence was analyzed by Poisson regression. The time to first event was analyzed by the product limit method. Device performance was disaggregated into confirmed malfunctions and system failures. The latter were events in which patients could not be rescued with backup circulatory support measures.. The 1-year survival rate was 52% (95% confidence limit [CL]; 40%-63%) for LVAD patients versus 28% (95% CL; 17%-39%) for medical patients and the 2-year survival rate was 29% (95% CL; 19%-40%) for LVAD patients versus 13% (95% CL; 5%-22%) for medical patients. System failure was 0.13 per patient per year and the confirmed LVAD malfunction rate was 0.90. Freedom from device replacement was 87% at 1 year and 37% at 2 years.. Despite the observed rates of device malfunction and replacement, LVAD implantation confers clinically significant improvement with regard to survival as compared with medical management. Device modifications and innovations for infection management exhibit great promise of improving device performance in the near future.

Topics: Aged; Cardiovascular Agents; Cause of Death; Female; Heart Failure; Heart-Assist Devices; Hemorrhage; Humans; Male; Middle Aged; Poisson Distribution; Prosthesis Failure; Sepsis; Stroke; Survival Rate

Blood pressure is not optimally reduced in 3 of 4 patients with hypertension (HTN) in the United States.. We analyzed for factors associations with premorbid non-adherence to HTN medications in acute stroke patients.. This cross-sectional study included 225 acute stroke patients with self-reported adherence to HTM medications in a stroke registry in the Southeastern United States. We defined medication non-adherence as < 90% of prescribed. Logistic regression analyzed demographic and socioeconomic factors for prediction of adherence.. There were 145 (64%) patients with adherence and 80 (36%) with non-adherence. The likelihood of adherence to HTN medications was decreased among black patients, OR 0.49 (95% CI 0.26-0.93), p = 0.03, and those without health insurance, OR 0.29 (95% CI 0.13-0.64), p = 0.002. Specific reasons for non-adherence were high medication cost in 26 (33%), side effects in 8 (10%), and other unspecified reasons in 46 (58%) patients.. In this study, adherence to HTN medications was significantly lower among black patients and those without health insurance.

Topics: Antihypertensive Agents; Cardiovascular Agents; Cross-Sectional Studies; Humans; Hypertension; Medication Adherence; Stroke; United States

Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascertained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence.. One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography-mass spectrometry (LC-MS/MS). Patients were classified as adherent or non-adherent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual variables and model fitting was undertaken for significant variables.. The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In univariate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01).. LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events.

Topics: Cardiovascular Agents; Chromatography, Liquid; Humans; Ischemic Attack, Transient; Secondary Prevention; Stroke; Tandem Mass Spectrometry

Topics: Angioplasty; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Constriction, Pathologic; Humans; Intracranial Arterial Diseases; Ischemic Attack, Transient; Risk; Stents; Stroke; Treatment Outcome

Topics: Angioplasty; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Constriction, Pathologic; Humans; Intracranial Arterial Diseases; Ischemic Attack, Transient; Stents; Stroke; Treatment Outcome

US and European guidelines diverge on whether to vaccinate adults who are not at high risk for cardiovascular events against influenza. Here, we investigated the associations between influenza vaccination and risk for acute myocardial infarction, stroke and pulmonary embolism during the 2009 pandemic in Norway, when vaccination was recommended to all adults.. Using national registers, we studied all vaccinated Norwegian individuals who suffered AMI, stroke, or pulmonary embolism from May 1, 2009 through September 30, 2010. We defined higher-risk individuals as those using anti-diabetic, anti-obesity, anti-thrombotic, pulmonary or cardiovascular medications (i.e. individuals to whom vaccination was routinely recommended); all other individuals were regarded as having lower-risk. We estimated incidence rate ratios with 95% CI using conditional Poisson regression in the pre-defined risk periods up to 180 days following vaccination compared to an unexposed time-period, with adjustment for season or daily temperature.. Overall, we observed lower risk for cardiovascular events following influenza vaccination. When stratified by baseline risk, we observed lower risk across all three outcomes in association with vaccination among higher-risk individuals. In this subgroup, relative risks were 0.72 (0.59-0.88) for AMI, 0.77 (0.59-0.99) for stroke, and 0.73 (0.45-1.19) for pulmonary embolism in the period 1-14 days following vaccination when compared to the background period. These associations remained essentially the same up to 180 days after vaccination. In contrast, the corresponding relative risks among subjects not using medications were 4.19 (2.69-6.52), 1.73 (0.91-3.31) and 2.35 (0.78-7.06).. In this nationwide study, influenza vaccination was associated with overall cardiovascular benefit. This benefit was concentrated among those at higher cardiovascular risk as defined by medication use. In contrast, our results demonstrate no comparable inverse association with thrombosis-related cardiovascular events following vaccination among those free of cardiovascular medications at baseline. These results may inform the risk-benefit balance for universal influenza vaccination.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Female; Heart Disease Risk Factors; Humans; Incidence; Influenza Vaccines; Influenza, Human; Male; Mass Vaccination; Middle Aged; Myocardial Infarction; Norway; Prognosis; Pulmonary Embolism; Registries; Risk Assessment; Stroke; Time Factors

Using claims databases of a public healthcare program (Quebec) for the years 2010-2013, we conducted a cohort study of patients with acute ischemic stroke (AIS) to describe secondary prevention treatments and determine how they stood against practice guidelines. We compared the risk of death or AIS recurrence over 1 year in patients treated with anticoagulants, antiplatelets, and/or other cardiovascular drugs. In the month after discharge, 44.3% of the patients did not receive the recommended treatment and > 20% did not have any treatment. Untreated patients were younger, had less comorbidities, and a more severe AIS. Anticoagulants and antiplatelets were associated with a reduced risk of death or recurrence (hazard ratio (HR) 0.27; 95% confidence interval (CI) 0.20-0.36 and HR 0.25; 95% CI 0.16-0.38, respectively) compared with the untreated group. Effect size was similar for the other treatments. Findings confirm treatment benefits shown in clinical trials and emphasize the importance of AIS secondary prevention.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Cardiovascular Agents; Cohort Studies; Comorbidity; Female; Guideline Adherence; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Proportional Hazards Models; Recurrence; Risk Factors; Secondary Prevention; Stroke

Topics: Anticoagulants; Atrial Fibrillation; Betacoronavirus; Cardiovascular Agents; Coronavirus Infections; COVID-19; Delivery of Health Care; Drug Monitoring; Evidence-Based Pharmacy Practice; Humans; Medication Adherence; Medication Systems; Pandemics; Pneumonia, Viral; Quarantine; Recurrence; SARS-CoV-2; Secondary Prevention; Stroke

 The ABC (age, biomarkers, and clinical history)-stroke and ABC-bleeding are biomarker-based scores proposed to predict stroke and bleeding, but non-specificity of biomarkers is common, predicting different clinical events at the same time. We assessed the predictive performance of the ABC-stroke and ABC-bleeding scores, for outcomes beyond ischemic stroke and major bleeding, in a cohort of atrial fibrillation (AF) patients..  We included AF patients stable on vitamin K antagonists for 6 months. The ABC-stroke and ABC-bleeding were calculated and the predictive values for myocardial infarction (MI), acute heart failure (HF), a composite of cardiovascular events, and all-cause deaths were compared..  We included 1,044 patients (49.2% male; median age 76 [71-81] years). During 6.5 (4.3-7.9) years, there were 58 (5.6%) MIs, 98 (9.4%) acute HFs, 167 (16%) cardiovascular events, and 418 (40%) all-cause deaths. There were no differences in mean ABC-stroke and ABC-bleeding scores in patients with/without MI (.  In AF patients, the ABC-stroke and ABC-bleeding scores demonstrated similar predictive ability for outcomes beyond stroke and bleeding, including MI, acute HF, a composite of cardiovascular events, and all-cause deaths. This is consistent with nonspecificity of biomarkers that predict "sick" patients or poor prognosis overall.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Area Under Curve; Atrial Fibrillation; Biomarkers; Cardiovascular Agents; Cause of Death; Comorbidity; Death, Sudden, Cardiac; Decision Support Techniques; Female; Heart Failure; Hemorrhage; Humans; Male; Mortality; Myocardial Infarction; Platelet Aggregation Inhibitors; Prognosis; ROC Curve; Severity of Illness Index; Stroke; Vitamin K

To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography.. A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes.. All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG.. Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.

Topics: Aged; Cardiovascular Agents; Cause of Death; Chronic Disease; Coronary Angiography; Coronary Artery Disease; Endovascular Procedures; Female; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Predictive Value of Tests; Prospective Studies; Referral and Consultation; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome

New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance.. To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction.. We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant.. We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation.. New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Topics: Age Factors; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Agents; Coronary Angiography; Female; Heart Failure; Hospital Mortality; Hospitalization; Humans; Incidence; Length of Stay; Male; Middle Aged; Myocardial Reperfusion; Portugal; Predictive Value of Tests; Recurrence; Retrospective Studies; ST Elevation Myocardial Infarction; Stents; Stroke; Stroke Volume; Survival Analysis; Thrombectomy

Atrial fibrillation (AF) is increasingly common among Australia's ageing population and carries significant morbidity and mortality. Its detection through screening, cardiac device interrogation and/or symptoms of AF brings with it a number of significant clinical issues.. The aim of this article is to outline a systematic approach to the management of patients with AF, including the initial investigations required, rhythm versus rate control, anticoagulation for stroke prevention, and the interplay between AF and heart failure.. Most patients with AF can be managed safely and effectively in the primary care setting. Rhythm control is pursued early in certain patients with AF who are at risk of decompensated heart failure. Specialist cardiology input is important in the treatment of AF coinciding with clinical heart failure, and for patients with medically refractory symptoms or slow/rapid heart rates.

Topics: Anticoagulants; Atrial Fibrillation; Cardiovascular Agents; Catheter Ablation; Electric Countershock; Electrocardiography, Ambulatory; Exercise Therapy; Healthy Lifestyle; Heart Failure; Humans; Pacemaker, Artificial; Risk Factors; Stroke

Despite the progress in the management of patients with adult congenital heart disease (ACHD), a significant proportion of patients still develop pulmonary hypertension (PH). We aimed to highlight the rate of the complications in PH-ACHD and the predicting factors of cumulative mortality risk in this population.. Data were obtained from the cohort of the national registry of ACHD in Greece from February 2012 until January 2018.. Overall, 65 patients receiving PH-specific therapy were included (mean age 46.1±14.4 years, 64.6% females). Heavily symptomatic (New York Heart Association (NYHA) class III/IV) were 53.8% of patients. The majority received monotherapy, while combination therapy was administered in 41.5% of patients. Cardiac arrhythmia was reported in 30.8%, endocarditis in 1.5%, stroke in 4.6%, pulmonary arterial thrombosis in 6.2%, haemoptysis in 3.1% and hospitalisation due to heart failure (HF) in 23.1%. Over a median follow-up of 3 years (range 1-6), 12 (18.5%) patients died. On univariate Cox regression analysis history of HF hospitalisation emerged as a strong predictor of mortality (HR 8.91, 95% CI 2.64 to 30.02, p<0.001), which remained significant after adjustment for age and for NYHA functional class.. Long-term complications are common among patients with PH-ACHD. Hospitalisations for HF predict mortality and should be considered in the risk stratification of this population.

Topics: Adult; Arrhythmias, Cardiac; Cardiovascular Agents; Female; Follow-Up Studies; Greece; Heart Defects, Congenital; Heart Failure; Hospitalization; Humans; Hypertension, Pulmonary; Male; Middle Aged; Mortality; Prognosis; Registries; Risk Assessment; Stroke

To identify whether, and to what extent, treatment with cardiovascular drugs and neurotropic drugs are associated with postural control and falls in patients with acute stroke.. Observational cohort study.. A stroke unit at a university hospital.. A consecutive sample of patients (N=504) with acute stroke.. Not applicable.. Postural control was assessed using the modified version of the Postural Assessment Scale for Stroke Patients. Data including baseline characteristics, all drug treatments, and falls were derived from medical records. Univariable and multivariable logistic regression and Cox proportional hazards models were used to analyze the association of drug treatment and baseline characteristics with postural control and with falls.. In the multivariable logistic regression analysis, factors significantly associated with impaired postural control were treatment with neurotropic drugs (eg, opioids, sedatives, hypnotics, antidepressants) with an odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.01-2.97, P=.046); treatment with opioids (OR 9.23, 95% CI, 1.58-54.00, P=0.014); age (OR 1.09, 95% CI, 1.07-1.12, P<.0001), stroke severity, which had a high National Institutes of Health Stroke Scale-score (OR 1.29, 95% CI, 1.15-1.45, P<.0001), and sedentary life style (OR 4.32, 95% CI, 1.32-14.17, P=.016). No association was found between neurotropic drugs or cardiovascular drugs and falls.. Treatment with neurotropic drugs, particularly opioids, in the acute phase after stroke, is associated with impaired postural control. Since impaired postural control is the major cause of falls in patients with acute stroke, these results suggest opioids should be used with caution in these patients.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Central Nervous System Agents; Female; Humans; Male; Postural Balance; Stroke

Recent advances in best medical therapy (BMT) has been associated with reduced risk of stroke similar to that observed following surgical carotid revascularization (CR). Thus, it remains uncertain which subset(s) of patients would benefit from prophylactic CR+BMT for asymptomatic carotid stenosis (ACS) over BMT alone. The purpose of this study was to analyze the contemporary experience in the management of >70% ACS in an academic institution, to compare the short- and long-term outcomes of BMT alone against CR+BMT, and to identify risk factors for the development of future cerebrovascular events.. A retrospective review of all patients with severe ACS between January 2005 and December 2012 at Loyola University Medical Center and its affiliated Edward Hines Jr. Veterans Administration Hospital was conducted. Baseline patient characteristics, medications, and follow-up data were collected from electronic medical records, and treatment outcomes were compared. The random forest method was performed to select potential important variables for the development of late stroke. The recursive partitioning regression analysis (RPRA) was performed to identify the patient subgroup at increased risk of future stroke.. Of 409 patients identified; 247 were treated with CR and 162 with BMT. Between these groups with CR+BMT and BMT alone, the mean age was 69.1±8.2 versus 75.5±9.0, respectively (P<0.01). Mean follow-up was 60.7±37.5 months. Early (30-day) outcomes of stroke, acute myocardial infarction or mortality did not differ between the treatment modalities (2.0% CR vs. 0.6% BMT, P=0.41). Probability of freedom from ipsilateral stroke, and any stroke at 1- and 5-year follow-up were also comparable between CR+BMT and BMT alone. However, random forest method and RPRA demonstrated that patients with history of diabetes and remote stroke treated with BMT alone were at a high risk for future stroke (36.4% in total, 7.2% per year). The diabetics with contralateral carotid stenosis >50% who are active smokers are at the highest risk for stroke after CR (20.0% in total, 4.0% per year).. Prophylactic CR+BMT does not provide overall late stroke prevention compared with BMT alone. Diabetics with a history of stroke, in particular, are at an increased risk of stroke despite BMT. Timely CR+BMT for high-risk patients is still indicated.

Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Illinois; Male; Middle Aged; Myocardial Infarction; Regression Analysis; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Topics: Anticoagulants; Atrial Flutter; Cardiovascular Agents; Diltiazem; Electric Countershock; Electrocardiography; Heart Block; Humans; Male; Middle Aged; Stroke

Carotid artery web is considered an exceptional cause of recurrent ischemic strokes in the affected arterial territory. The underlying pathology proposed for this entity is an atypical fibromuscular dysplasia. We present the case of a 43-year-old woman with no cardiovascular risk factors who had experienced 2 cryptogenic ischemic strokes in the same arterial territory within an 11-month period. Although all diagnostic tests initially yielded normal results, detailed analysis of the computed tomography angiography images revealed a carotid web; catheter angiography subsequently confirmed the diagnosis. Carotid surgery was performed, since which time the patient has remained completely asymptomatic. The histological finding of intimal hyperplasia is consistent with previously reported cases of carotid artery web. Carotid artery web is an infrequent cause of stroke, and this diagnosis requires a high level of suspicion plus a detailed analysis of vascular imaging studies.

Topics: Adult; Aspirin; Atorvastatin; Biopsy; Brain Ischemia; Cardiovascular Agents; Carotid Artery Diseases; Carotid Artery, Internal; Computed Tomography Angiography; Female; Fibromuscular Dysplasia; Humans; Hyperplasia; Neointima; Recurrence; Risk Factors; Stroke

Rationale Despite several large clinical trials assessing blood pressure lowering in acute stroke, equipoise remains particularly for ischemic stroke. The "Blood pressure in Acute Stroke Collaboration" commenced in the mid-1990s focussing on systematic reviews and meta-analysis of blood pressure lowering in acute stroke. From the start, Blood pressure in Acute Stroke Collaboration planned to assess safety and efficacy of blood pressure lowering in acute stroke using individual patient data. Aims To determine the optimal management of blood pressure in patients with acute stroke, including both intracerebral hemorrhage and ischemic stroke. Secondary aims are to assess which clinical and therapeutic factors may alter the optimal management of high blood pressure in patients with acute stroke and to assess the effect of vasoactive treatments on hemodynamic variables. Methods and design Individual patient data from randomized controlled trials of blood pressure management in participants with ischemic stroke and/or intracerebral hemorrhage enrolled during the ultra-acute (pre-hospital), hyper-acute (<6 h), acute (<48 h), and sub-acute (<168 h) phases of stroke. Study outcomes The primary effect variable will be functional outcome defined by the ordinal distribution of the modified Rankin Scale; analyses will also be carried out in pre-specified subgroups to assess the modifying effects of stroke-related and pre-stroke patient characteristics. Key secondary variables will include clinical, hemodynamic and neuroradiological variables; safety variables will comprise death and serious adverse events. Discussion Study questions will be addressed in stages, according to the protocol, before integrating these into a final overreaching analysis. We invite eligible trials to join the collaboration.

Topics: Blood Pressure; Brain Ischemia; Cardiovascular Agents; Cerebral Hemorrhage; Humans; Meta-Analysis as Topic; Randomized Controlled Trials as Topic; Stroke; Systematic Reviews as Topic

To report long-term results of stent placement and medical therapy for symptomatic and asymptomatic patients, respectively, with carotid artery near-occlusion with full collapse.. Between January 2008 and December 2010, 204 carotid arteries diagnosed by duplex scanning as exhibiting complete occlusion were re-examined with CT angiography; 46 arteries in 46 patients were patent with threadlike lumens and were reclassified as exhibiting near-occlusion with full collapse. Asymptomatic patients (n = 22) received best medical therapy (BMT) alone, and symptomatic patients (n = 24) were referred for carotid artery stent (CAS) placement plus BMT. Patients underwent clinical follow-up for 63.9 months ± 23.6 and duplex surveillance.. None of the 22 asymptomatic patients treated with BMT alone experienced neurologic events during the follow-up interval. Four died of unrelated causes, resulting in a cumulative survival rate of 81.8%. Technical failure occurred in 5 of 24 symptomatic patients, but none had perioperative complications related to inability to cross the near-occlusion. Of the 19 patients with procedural success, 1 developed immediate upper limb monoparesis; none had periprocedural myocardial infarction, and none died. At 60-month follow-up, patients who underwent successful CAS placement had neurologic event-free and cumulative survival rates of 89.4% and 89.4%; patients with failed recanalization had neurologic event-free and cumulative survival rates of 0% and 40.0% (P = .01).. Asymptomatic patients with carotid near-occlusion with full collapse experienced good outcomes with BMT alone. Symptomatic patients who underwent CAS placement demonstrated long-term survival and freedom from neurologic event rates comparable to those of asymptomatic patients.

Topics: Adult; Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Computed Tomography Angiography; Disease-Free Survival; Endovascular Procedures; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Prospective Studies; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Stroke; Treatment Outcome

It is unclear what factors providers take into account to determine the target blood pressure (BP) after mechanical thrombectomy (MT) in patients who had acute ischemic stroke. We aimed to understand practice patterns of post-MT BP management across institutions in the United States.. We surveyed StrokeNet institutions providing MT and post-MT care with an online questionnaire, designed to understand institutional post-MT BP management practices.. Of 131 potential institutions, 58 completed the survey. The majority of institutions target systolic BP (SBP, n = 53, 91%) during the first 24 hours post-MT (n = 32, 55%) using nicardipine as a first-line agent (n = 43, 74%). At most institutions, BP management is determined by a team of physicians in a collaborative fashion (n = 30, 52%) and individualized on a case-by-case basis (n = 39, 67%) after taking the reperfusion status into account (n = 42, 72%). In patients with successful reperfusion, 36% (n = 21) of the institutions target SBP in the range of 120-139 mm Hg, 21% (n = 12) target 140-159 mm Hg, and 28% (n = 16) would accept any value less than or equal to 180 mm Hg. In patients with unsuccessful reperfusion, 43% (n = 25) would accept any SBP value less than or equal to 180 mm Hg and 10% (n = 6) would target SBP less than or equal to 220 mm Hg.. We found that majority of the institutions do not have a standardized protocol for post-MT BP management. There was interinstitutional heterogeneity in the preferred target of SBP post-MT and most institutions target values of SBP lower than 180 mm Hg in post-MT patients. Prospective data and randomized control trial are needed to identify the optimal target BP.

Topics: Blood Pressure; Brain Ischemia; Cardiovascular Agents; Critical Care; Disease Management; Humans; Mechanical Thrombolysis; Nicardipine; Physicians; Stroke; Surveys and Questionnaires

The impact of treatment strategies on outcomes in patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) according to presenting angina has not been rigorously assessed.. We performed a patient-level pooled-analysis (n = 5027) of patients with stable CAD and T2DM randomized to optimal medical therapy [OMT], percutaneous coronary intervention [PCI] + OMT, or coronary artery bypass grafting [CABG] + OMT. Endpoints were death/myocardial infarction (MI)/stroke, post-randomization revascularization (both over 5 years), and angina control at 1 year.. Increasing severity of baseline angina was associated with higher rates of death/MI/stroke (p = 0.009) and increased need for post-randomization revascularization (p = 0.001); after multivariable adjustment, only association with post-randomization revascularization remained significant. Baseline angina severity did not influence the superiority of CABG + OMT to reduce the rate of death/MI/stroke and post-randomization revascularization compared to other strategies. CABG + OMT was superior for angina control at 1 year compared to both PCI + OMT and OMT alone but only in patients with ≥ Class II severity at baseline. Comparisons between PCI + OMT and OMT were neutral except that PCI + OMT was superior to OMT for reducing the rate of post-randomization revascularization irrespective of presenting angina severity.. Presenting angina severity did not influence the superiority of CABG + OMT with respect to 5-year rates of death/MI/stroke and need for post-randomization revascularization. Presenting angina severity minimally influenced relative benefits for angina control at 1 year.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus, Type 2; Female; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Retreatment; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Diet, Healthy; Humans; Prognosis; Risk Factors; Risk Reduction Behavior; Stroke

To improve outcomes in patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention remain an unmet clinical need. The study aimed to evaluate the efficacy and safety of G2-DESs and BP-DESs in patients with and without DM in a single center in China.. A total of 7666 consecutive patients who exclusively had G2-DES or BP-DES implantation throughout 2013 in our center were studied. The primary efficacy endpoint was any target lesion revascularization (TLR), whereas the primary safety endpoint was a composite of death or myocardial infarction (MI) at 2-year follow-up.. G2-DESs had a similar occurrence of death, non-fatal MI, TLR, stroke, and stent thrombosis compared with BP-DESs in patients with DM (all P > 0.05). The incidence of TVR and TLR was lower for G2-DESs than for BP-DESs in patients without DM (3.2% vs. 5.1%, P = 0.002; 2.2% vs. 4.5%, P < 0.001, respectively). Kaplan-Meier analysis also showed better TVR- and TLR-free survival rates for G2-DESs than for BP-DESs in patients without DM. Multivariate analysis showed that a BP-DES was an independent risk factor for TLR (hazard ratio 1.963, 95% confidence interval 1.390-2.772, P < 0.001) in patients without DM, which was not predictive of other components of major adverse cardiac events (P > 0.05).. G2-DESs have better efficacy, represented by a reduced risk of TLR, and similar safety compared with BP-DESs in patients without DM. G2-DESs have similar efficacy and safety compared with BP-DESs in patients with DM at 2-year follow-up.

Topics: Absorbable Implants; Cardiovascular Agents; China; Coronary Angiography; Coronary Artery Disease; Diabetes Mellitus; Drug-Eluting Stents; Humans; Incidence; Percutaneous Coronary Intervention; Polymers; Prospective Studies; Prosthesis Design; Recurrence; Risk Factors; Stroke; Time Factors; Treatment Outcome

Long-term progression of peripheral arterial disease (PAD) as initial manifestation of atherosclerotic arterial disease is not well described. Cardiovascular (CV) risk was examined in different PAD populations diagnosed in a hospital setting in Sweden.. Data for this retrospective cohort study were retrieved by linking data on morbidity, medication use, and mortality from Swedish national registries. Primary CV outcome was a composite of myocardial infarction, ischemic stroke (IS), and CV death. Kaplan-Meier analysis and Cox proportional hazards modeling was used for describing risk and relative risk.. Of 66,189 patients with an incident PAD diagnosis (2006-2013), 40,136 had primary PAD, 16,786 had PAD + coronary heart disease (CHD), 5803 had PAD + IS, and 3464 had PAD + IS + CHD. One-year cumulative incidence rates of major CV events for the groups were 12%, 21%, 29%, and 34%, respectively. Corresponding numbers for 1-year all-cause death were 16%, 22%, 33%, and 35%. Compared with the primary PAD population, the relative risk increase for CV events was highest in patients with PAD + IS + CHD (hazard ratio [HR], 2.01), followed by PAD + IS (HR, 1.87) and PAD + CHD (HR, 1.42). Despite being younger, the primary PAD population was less intensively treated with secondary preventive drug therapy.. PAD as initial manifestation of atherosclerotic disease diagnosed in a hospital-based setting conferred a high risk: one in eight patients experienced a major CV event and one in six patients died within 1 year. Despite younger age and substantial risk of future major CV events, patients with primary PAD received less intensive secondary preventive drug therapy.

Topics: Age Factors; Aged; Aged, 80 and over; Ambulatory Care; Brain Ischemia; Cardiovascular Agents; Cause of Death; Comorbidity; Disease Progression; Female; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Peripheral Arterial Disease; Prevalence; Prognosis; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Sweden; Time Factors

Diabetes mellitus (DM), low ejection fraction (EF), and the extent of coronary artery disease (CAD) have all been identified as predictors of cardiovascular events in multivessel disease, but their comparative contributions to future risk remain unclear in patients with unprotected left main coronary artery (ULMCA) disease. Through this study we aimed to categorize the risk for cardiovascular events in patients with ULMCA disease using simple clinical descriptors.. Our study included a total of 5975 patients with ULMCA disease from the Interventional Research Incorporation Society-Left MAIN Revascularization registry who were treated with percutaneous coronary intervention (n=2850), coronary artery bypass grafting (n=2337), or medical therapy alone (n=608). We categorized the risk for cardiovascular events using simple clinical descriptors (DM, low EF, and the extent of CAD). The primary outcome was a major adverse cardiac or cerebrovascular event (MACCE) (i.e. death from any cause, stroke, myocardial infarction, or repeat revascularization).. Overall, the 5-year rate of MACCE was highest in the medical group, lower in the percutaneous coronary intervention group, and lowest in the coronary artery bypass grafting group (42.5, 25.7, and 19.9%, respectively; P<0.001). In multivariable modeling, the presence of DM [hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.12-1.40; P<0.001], low EF of 40% or less (HR: 1.83; 95% CI: 1.56-2.15; P<0.001), and the extent of CAD (HR: 1.14; 95% CI: 1.08-1.21; P<0.001) were independent predictors of MACCE; in addition, these factors were consistently associated with a significantly higher risk for MACCE, regardless of index treatment strategies.. Simple clinical descriptors can assist clinicians in identifying high-risk patients and in predicting future cardiovascular events within the broad range of risk factors for ULMCA disease.

Topics: Aged; Asia; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Bypass; Coronary Artery Disease; Coronary Stenosis; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Percutaneous Coronary Intervention; Proportional Hazards Models; Registries; Retreatment; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome

Identifying predictive factors for major cardiovascular events and death in patients with unprotected left main coronary artery disease is of great clinical value for risk stratification and possible guidance for tailored preventive strategies.. The Interventional Research Incorporation Society-Left MAIN Revascularization registry included 5795 patients with unprotected left main coronary artery disease (percutaneous coronary intervention, n=2850; coronary-artery bypass grafting, n=2337; medication alone, n=608). We analyzed the incidence and independent predictors of major adverse cardiac and cerebrovascular events (MACCE; a composite of death, MI, stroke, or repeat revascularization) and all-cause mortality in each treatment stratum. During follow-up (median, 4.3 years), the rates of MACCE and death were substantially higher in the medical group than in the percutaneous coronary intervention and coronary-artery bypass grafting groups (. Among patients with unprotected left main coronary artery disease, the key clinical predictors for MACCE and death were generally similar regardless of index treatment. This study provides effect estimates for clinically relevant predictors of long-term clinical outcomes in real-world left main coronary artery patients, providing possible guidance for tailored preventive strategies.. URL: https://clinicaltrials.gov. Unique identifier: NCT01341327.

Topics: Aged; Asia; Cardiovascular Agents; Cause of Death; Comorbidity; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Proportional Hazards Models; Registries; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Carotid Artery Diseases; Clinical Decision-Making; Endarterectomy, Carotid; Endovascular Procedures; Humans; Patient Selection; Risk Factors; Stents; Stroke; Treatment Outcome

Objective Age screening and preventive medication for future myocardial infarction and stroke has been previously described. We aimed to ascertain whether different age cut-offs are needed for males and females. Methods We determined five parameters for each sex according to age cut-off: detection rate (sensitivity), false-positive rate, proportion of the population eligible for treatment with a polypill, proportion who benefit from taking a polypill (simvastatin 20 mg, losartan 25 mg, hydrochlorothiazide 12.5 mg, amlodipine 2.5 mg), and among these, years of life gained without a first myocardial infarction or stroke. Results Approximately one-third benefit, regardless of the age cut-off. For males and females combined, using ages 40 and 80, the detection rates are 98% and 52%, false-positive rates are 51% and 7%, population percentages eligible for treatment are 52% and 7%, and years of life gained without a first myocardial infarction or stroke are 8.4 and 3.6. Using age 50, detection rates are 93% (males) 98% (females), false-positive rates 37% (males) 40% (females), percentage of the population eligible for treatment 38% (males) 41% (females), percentage who benefit 35% (males) 33% (females), and years of life gained without an event 8.5 (males) 7.0 (females). At a given age cut-off, the sex differences are relatively small. Conclusion A single age cut-off can be used for both sexes.

Topics: Adult; Age Factors; Aged; Cardiovascular Agents; Drug Combinations; Female; Humans; Hydrochlorothiazide; Losartan; Male; Middle Aged; Myocardial Infarction; Preventive Health Services; Simvastatin; State Medicine; Stroke; United Kingdom

Individuals who present to the emergency departments of safety-net systems often have poorly controlled risk factors due to lack of primary care. Little is known about potential differences in presenting characteristics, discharge medications, and discharge destinations of patients with acute ischemic stroke (AIS) who present to safety-net settings versus university medical centers (UMCs).. Demographic characteristics, medical history, premorbid medication use, stroke severity, discharge medications, and discharge destination were assessed among consecutive admissions for AIS over a 2-year period at a UMC (n = 385) versus 2 university-affiliated safety-net hospitals (SNHs) (n = 346) in Los Angeles County.. Compared with patients presenting to the UMC, individuals admitted to the SNHs were younger, more frequently male, nonwhite, current smokers, hypertensive, and diabetic; they were less likely to take antithrombotics and statins before admission, and had worse serum lipid and glycemic markers (all P < .05). Patients admitted to the UMC trended toward more cardioembolic strokes and had higher stroke severity scores (P < .0001). At discharge, patients admitted to the SNHs were more likely to receive antihypertensive medications than do patients admitted to the UMC (P < .001), but there were no differences in prescription of antiplatelet medications or statins.. Individuals with AIS admitted to SNHs in Los Angeles County are younger and have poorer vascular risk factor control than their counterparts at a UMC. Discharge treatment does not vary considerably between systems. Early and more vigorous efforts at primary vascular risk reduction among patients seen at SNHs may be warranted to reduce disparities.

Topics: Academic Medical Centers; Age Factors; Aged; Aged, 80 and over; Brain Ischemia; Cardiovascular Agents; Comorbidity; Drug Prescriptions; Emergency Medical Services; Female; Health Status Disparities; Healthcare Disparities; Humans; Life Style; Los Angeles; Male; Middle Aged; Patient Admission; Patient Discharge; Risk Factors; Safety-net Providers; Stroke; Time Factors

Chronic kidney disease (CKD) is an important risk factor for coronary artery disease (CAD) and cardiovascular events. Cystatin C (CysC) has been proposed as a sensitive marker for CKD. However, the predictive value of CysC for cardiovascular events in CAD patients with preserved estimated glomerular filtration rate (eGFR) is unclear. We enrolled 277 consecutive patients undergoing elective percutaneous coronary intervention with sirolimus-eluting stents (SES). Patients with an eGFR ≤60 ml/min/1.73 m(2) were excluded. Serum CysC levels were measured immediately before SES implantation. Major adverse cardiac and cerebrovascular events (MACCE) were defined as cardiovascular death, acute coronary syndrome, stroke, and hospitalization because of congestive heart failure. After a median follow-up of 63 months, 29 patients had MACCE. The subjects were divided into 2 groups based on median serum CysC levels and eGFR (0.637 mg/L and 72.43 ml/min/1.73 m(2), respectively). Kaplan-Meier curves showed that the high CysC group had a significantly higher occurrence of MACCE than the low CysC group (p = 0.006), although a low level of eGFR was not significantly associated with an increased risk for occurrence of MACCE. Multivariate analysis revealed that serum CysC levels were an independent predictor of MACCE [hazards ratio: 1.30 per 0.1 mg/L (1.01-1.63), p = 0.038]. These data suggested that serum CysC level is an independent predictor of MACCE, even in patients with preserved eGFR after elective SES implantation.

Topics: Acute Coronary Syndrome; Aged; Biomarkers; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Disease; Cystatin C; Drug-Eluting Stents; Female; Glomerular Filtration Rate; Heart Failure; Humans; Kaplan-Meier Estimate; Kidney; Male; Middle Aged; Multivariate Analysis; Percutaneous Coronary Intervention; Proportional Hazards Models; Renal Insufficiency, Chronic; Retrospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stroke; Time Factors; Treatment Outcome; Up-Regulation

Stroke is a major health problem with important morbidity and mortality. Various risk factors and cardiovascular medication groups are known to have an influence on stroke incidence, but less is known about the relation between medication use and stroke severity.. To determine if relationships exist between the pre-stroke cardiovascular medication use and stroke severity.. A retrospective study was conducted on a database with anonymized data of 1974 patients with a suspected stroke, admitted to the Universitair Ziekenhuis (UZ) Brussel. Stroke severity was quantified using the National Institute of Health Stroke Scale (NIHSS). Cardiovascular medication groups were first included in a multivariable linear regression model. Second, to obtain clinically interpretable results, all variables that were retained in the final linear regression model were introduced in a cumulative odds ordinal logistic regression model with proportional odds.. Angiotensin II receptor blockers (ARBs), statins, and antiarrhythmics were significantly associated with stroke severity at the 10 % α level in a multivariable linear regression model, suggesting a possible effect of these medication groups on stroke severity. Only pre-stroke statin use showed a significant relationship with the NIHSS score in the ordinal logistic regression model with an adjusted odds ratio of 0.740 (95 % CI 0.580-0.944; p = 0.015).. Pre-stroke use of statins is significantly associated with lower stroke severity. No significant relationship was detected between pre-stroke use of other medication groups and stroke severity, defined by the NIHSS score.

Topics: Aged; Angiotensin Receptor Antagonists; Anti-Asthmatic Agents; Cardiovascular Agents; Cardiovascular Diseases; Female; Hospitalization; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Logistic Models; Male; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Treatment Outcome

Does the use of post-menopausal vaginal estradiol (VE) affect the mortality risk for coronary heart disease (CHD) and stroke.. The use of VE reduces the risk for cardiovascular mortality.. A growing number of women use VE for post-menopausal genitourinary symptoms. Although this therapy is intended to have only local effects, estrogen is absorbed into the blood circulation and thus VE use may also have systemic effects.. We studied a nationwide cohort in Finland 1994-2009 during which post-menopausal women (n = 195 756) initiated the use of VE (age [mean ± SD] 65.7 ± 10.9 years). Follow-up data gathered 1.4 million women-years and we assessed the mortality risk due to CHD (n= 9656) or stroke (n = 4294).. The mortality risk in VE users was compared with that in the age-matched background population (standardized mortality ratio; [SMR]; 95% confidence interval) and related to various durations of exposure to VE (1 to ≤3, >3 to ≤5, >5 to ≤10 and >10 years).. The use of VE was accompanied by decreases in the risk for CHD and stroke death. The risk reduction for CHD death was highest for >3 to ≤5 years exposure (SMR 0.64; 0.57-0.70) and for stroke for >5 to ≤10 years exposure (SMR 0.64; 0.57-0.72). The risk reductions for both CHD and stroke mortality were detected in all age groups with the highest risk reduction being in women aged 50-59 years (SMR 0.43; 0.19-0.88 and SMR 0.21; 0.06-0.58, respectively).. Our series lack a placebo arm and thus, may harbor a healthy woman bias. Moreover, data on clinical variables such as weight, smoking, blood pressure and family background were unobtainable for this study. Women using both VE and systemic hormone therapy (HT) were included in the comparator background population. This should not cause any significant error because the proportion of women using VE or other HT was modest (<10% in age-matched population) and because the use of systemic HT also reduces death risks in the same population. Our data cannot be directly applied for local regimens containing conjugated equine estrogens, because they are absorbed differently and may show effects that differ from those of estradiol.. In 1000 women using VE for up to 10 years, a maximum of 24 fewer CHD deaths and 18 fewer stroke deaths is likely to occur.. This work was supported by unrestricted grants from the Päivikki and Sakari Sohlberg Foundation, the Emil Aaltonen Foundation, the Finnish Medical Foundation, Finska Läkaresällskapet, the Orion Farmos Research Foundation, the Paavo Nurmi Foundation and a special governmental grant for health sciences research. The funding sources had no role in the study design, data handling or manuscript preparation. EPID Research is a company that performs financially supported studies for several pharmaceutical companies. Dr Korhonen, Dr Hoti and MSc Vattulainen, employed by Epid Research, report financial activities from several other pharmaceutical companies outside the submitted work. Dr Mikkola has been a speaker and/or received consulting fees from Mylan and Novo Nordisk. Dr Tuomikoski has been a speaker and/or received consulting fees from Orion and Mylan. The remaining authors report no conflict of interest.

Topics: Aged; Cardiovascular Agents; Cohort Studies; Coronary Disease; Delayed-Action Preparations; Drug Prescriptions; Estradiol; Estrogens; Female; Female Urogenital Diseases; Finland; Follow-Up Studies; Humans; Middle Aged; Postmenopause; Registries; Risk Factors; Stroke; Vaginal Creams, Foams, and Jellies

The primary prevention of cardiovascular disease is a public health priority. To assess the costs and benefits of a Polypill Prevention Programme using a daily 4-component polypill from age 50 in the UK, we determined the life years gained without a first myocardial infarction (MI) or stroke, together with the total service cost (or saving) and the net cost (or saving) per year of life gained without a first MI or stroke. This was estimated on the basis of a 50 % uptake and a previously published 83 % treatment adherence. The total years of life gained without a first MI or stroke in a mature programme is 990,000 each year in the UK. If the cost of the Polypill Prevention Programme were £1 per person per day, the total cost would be £4.76 bn and, given the savings (at 2014 prices) of £2.65 bn arising from the disease prevented, there would be a net cost of £2.11 bn representing a net cost per year of life gained without a first MI or stroke of £2120. The results are robust to sensitivity analyses. A national Polypill Prevention Programme would have a substantial effect in preventing MIs and strokes and be cost-effective.

Topics: Aged; Aged, 80 and over; Amlodipine; Aspirin; Cardiovascular Agents; Case-Control Studies; Cohort Studies; Cost-Benefit Analysis; Humans; Hydrochlorothiazide; Losartan; Markov Chains; Middle Aged; Myocardial Infarction; Polypharmacy; Primary Prevention; Quality-Adjusted Life Years; Simvastatin; Stroke; United Kingdom

To understand the perspectives of stroke survivors, caregivers and general practitioners (GPs) on a polypill approach, consisting of blood pressure and cholesterol-lowering therapies, with or without aspirin, for the secondary prevention of stroke.. A qualitative interview study was undertaken in 5 GP surgeries in the East of England. 28 survivors of stroke/transient ischaemic attack (TIA) were interviewed, 14 of them with a caregiver present, along with a convenience sample of 5 GPs, to assess attitudes towards a polypill and future use. Topic guides explored participants attitudes, potential uptake and long-term use, management of polypill medication and factors influencing the decision to prescribe. Data were analysed using a grounded theory approach. Key themes are presented and illustrated with verbatim quotes.. The analysis identified 3 key themes: polypill benefits, polypill concerns and polypill lessons for implementation. Stroke/TIA survivors were positive about the polypill concept and considered it acceptable in the secondary prevention of stroke. Perceived benefits of a polypill included convenience resulting in improved adherence and reduced burden of treatment. Caregivers felt that a polypill would improve medication-taking practices, and GPs were open to prescribing it to those at increased cardiovascular risk. However, concerns raised included whether a polypill provided equivalent therapeutic benefit, side effects through combining medications, consequences of non-adherence, lack of flexibility in regulating dosage, disruption to current treatment and suitability to the wider stroke population.. Participants acknowledged potential advantages in a polypill approach for secondary prevention of stroke; however, significant concerns remain. Further research on the efficacy of a polypill is needed to reassure practitioners whose concerns around inflexibility and treatment suitability are likely to influence the decision to prescribe a polypill for secondary prevention of stroke. Acceptability among survivors, caregivers and GPs is likely to determine the uptake and subsequent use of a polypill in the future.

Topics: Aged; Aged, 80 and over; Attitude of Health Personnel; Cardiovascular Agents; Caregivers; Female; General Practitioners; Humans; Male; Middle Aged; Patient Satisfaction; Qualitative Research; Secondary Prevention; Stroke; Survivors

In recent trials, after deducting the risks in the 30-day periprocedural period, the long-term risk of stroke or death was similar with carotid stenting (CAS) and endarterectomy (CEA) for asymptomatic carotid stenosis (ACS) - approximately 0.5% per year. These findings may exacerbate the problem of inappropriate routine intervention in ACS, being justified on the basis of an invalid comparison of the risks in the medical arms of clinical trials conducted decades ago (˜ 2% per year) to the risks in modern trials of CAS vs. CEA with no medical arm. Intervention is regarded as justified if it can be carried out with a risk below 3%. The annual risk of ipsilateral stroke or death in ACS with intensive medical therapy is now ˜ 0.5% - similar to the long-term risk after the periprocedural period in recent trials of intervention. However, periprocedural risk was ˜ 3% for CAS and 1.7% for CEA. Thus with modern CAS and CEA, the risk remains much higher than with modern medical therapy, even with careful vetting of the surgeons and interventionalists. In real world practice, documented in registries, the risks are much higher. National differences - 90% of carotid intervention for ACS in the US vs. 0% in Denmark - bring into question the advisability and ethics of routine intervention. A moratorium on routine intervention for ACS should be respected except in ongoing randomized trials comparing CAS, CEA and modern intensive medical therapy. Patients with high-risk ACS can be identified for appropriate intervention.

Topics: Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Risk; Stents; Stroke

Aspirin is known to reduce mortality and recurrent vascular events. However, there are no reports about the dose-response of loading aspirin in treating acute ischemic stroke. The objective of this study was to compare the effectiveness of different loading doses of aspirin in acute ischemic stroke presenting within 48 hours of symptom onset.. This was a retrospective, hospital-based cohort study. Patients were classified as high dose (160-325 mg) or low dose (<160 mg) based on the initial loading dose of aspirin at the emergency department. The primary outcome measure was a favorable modified Rankin Scale (mRS) score of 1 or lower on discharge. Secondary outcomes included in-hospital mortality, stroke progression during admission, and bleeding events. A propensity score with 1:3 matching was used to balance baseline characteristics, and stepwise multiple logistic regression was performed for variable adjustment.. From a total of 7738 available patients, 3802 patients were included. Among them, 750 patients were in the high-dose group. Multiple logistic regression after matching revealed that the high-dose group was significantly associated with a favorable clinical outcome on discharge (odds ratio: 1.49, 95% confidence interval: 1.17-1.89, P <.01), but not mortality or stroke progression. The high-dose group also experienced more minor bleeding events.. A higher loading dose of aspirin (160-325 mg) can be beneficial in treating acute ischemic stroke, although there is an increased risk of minor bleeding.

Topics: Aged; Aged, 80 and over; Aspirin; Brain Ischemia; Cardiovascular Agents; Disability Evaluation; Disease Progression; Female; Hemorrhage; Hospital Mortality; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Predictive Value of Tests; Propensity Score; Registries; Remission Induction; Retrospective Studies; Risk Factors; Stroke; Time Factors; Treatment Outcome

Aspirin is known to reduce stroke risk; however, its role in reducing severity of ischemic syndrome is not clear. We sought to investigate the relationship between antecedent aspirin use and stroke severity in patients presenting with acute ischemic stroke (AIS).. We retrospectively analyzed a prospectively collected database of consecutive AIS patients presenting to our center. Clinical characteristics (including antecedent aspirin use), imaging findings, and laboratory data were assessed in association with presenting stroke severity, as measured by the National Institutes of Health Stroke Scale (NIHSS). Logistic regression models were used to determine univariate and multivariate predictors of baseline NIHSS.. Of the 610 AIS patients with admission brain magnetic resonance imaging available for volumetric analysis of acute infarct size, 241 (39.5%) used aspirin prior to stroke onset. Antecedent aspirin use (P = .0005), history of atrial fibrillation (P < .0001), acute infarct volume (P < .0001), initial systolic blood pressure (P = .041), admission glucose level (P = .0027), and stroke subtype (P < .0001) were associated with presenting stroke severity in univariate analysis. Antecedent aspirin use (P < .0001), history of atrial fibrillation (P < .0002), acute infarct volume (P < .0001), systolic blood pressure (P = .038), and glucose level (P = .0095) remained independent predictors of NIHSS in multivariable analysis.. Antecedent aspirin use was independently associated with milder presenting stroke severity, even after accounting for acute infarct volume. While the underlying biology of this apparent protective relationship requires further study, patients at high risk of stroke may benefit from routine aspirin use.

Topics: Aged; Aged, 80 and over; Aspirin; Atrial Fibrillation; Biomarkers; Blood Glucose; Blood Pressure; Brain Ischemia; Cardiovascular Agents; Chi-Square Distribution; Databases, Factual; Diffusion Magnetic Resonance Imaging; Disability Evaluation; Female; Humans; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Patient Admission; Predictive Value of Tests; Protective Factors; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke

We sought to compare the benefit of percutaneous closure to that of medical therapy alone for the secondary prevention of embolism in patients with patent foramen ovale (PFO) and otherwise unexplained ischemic stroke, in a propensity scored study.. Between 2000 and 2012, we selected consecutive first-ever ischemic stroke patients aged 18 to 45 years with PFO and no other cause of brain ischemia, as part of the IPSYS registry (Italian Project on Stroke in Young Adults), who underwent either percutaneous PFO closure or medical therapy for comparative analysis. Primary end point was a composite of ischemic stroke, transient ischemic attack, or peripheral embolism. Secondary end point was brain ischemia. Five hundred and twenty-one patients qualified for the analysis. The primary end point occurred in 15 patients treated with percutaneous PFO closure (7.3%) versus 33 patients medically treated (10.5%; hazard ratio, 0.72; 95% confidence interval, 0.39-1.32; P=0.285). The rates of the secondary end point brain ischemia were also similar in the 2 treatment groups (6.3% in the PFO closure group versus 10.2% in the medically treated group; hazard ratio, 0.64; 95% confidence interval, 0.33-1.21; P=0.168). Closure provided a benefit in patients aged 18 to 36 years (hazard ratio, 0.19; 95% confidence interval, 0.04-0.81; P=0.026) and in those with a substantial right-to-left shunt size (hazard ratio, 0.19; 95% confidence interval, 0.05-0.68; P=0.011).. PFO closure seems as effective as medical therapy for secondary prevention of cryptogenic ischemic stroke. Whether device treatment might be more effective in selected cases, such as in patients younger than 37 years and in those with a substantial right-to-left shunt size, deserves further investigation.

Topics: Adolescent; Adult; Age Factors; Brain Ischemia; Cardiac Catheterization; Cardiovascular Agents; Chi-Square Distribution; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Humans; Intracranial Embolism; Italy; Male; Middle Aged; Propensity Score; Proportional Hazards Models; Registries; Risk Factors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome; Young Adult

The HOPE-3-Trial investigated the effect of primary prevention on cardio- and neurovascular events in patients without known atherosclerotic disease, but with intermediate risk. In a factorial design Rosuvastatin 10 mg, Candesartan 16 mg/HCT 12.5 mg or both were compared with placebo. Rosuvastatin effectively lowered LDL-cholesterol and the rate of cardio- and neurovascular complications with a NNT of approximately 500/year without detectable effect on mortalitiy. Candesartan 16 mg/HCT 12.5 mg did not influence any endpoint, however, the predefined subgroup of patients with hypertension level I had a benefit. Patients with systolic pressure <131 mmHg even trended towards a higher risk if treated. The combination of statin and blood pressure-lowering agents showed no additive effects. The benefit was solely the result of statin therapy alone. Primary prevention with Rosuvastatin can be recommended if the cardio- and neurovascular risk is 1-2%/year, independent of the initial LDL, although the NNT of 500-1400/year is high and mortalitiy is not decreased. Possibly there will be future studies with longer term follow up to verify a reduction in mortality. Therapy with Candesartan 16 mg/HCT 12,5 mg has a beneficial effect only in patients with hypertension. Further studies with different antihypertensives and more intensive blood pressure lowering are desirable. The approach of combining all three drugs within a poly-pill for primary prevention in an intermediate risk population without elevated blood pressure is not recommended.

Topics: Cardiovascular Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Myocardial Infarction; Stroke

The purpose of this study was to determine the association of socioeconomic factors on use of cardioprotective medicines in known coronary heart disease (CHD) or stroke in South Asia.. We enrolled 33,423 subjects aged 35-70 years (women 56%, rural 53%, low education 51%, low household wealth 25%) in 150 communities in India, Pakistan and Bangladesh during 2003-2009. Information regarding socioeconomic status, disease conditions and treatments was recorded. We studied influence of rural location, educational status and household wealth on use of drug therapies. Odds ratios (ORs) and 95% confidence intervals were calculated.. CHD was reported in 683 (2.0%), stroke 316 (0.9%), and CHD/stroke in 970 (2.9%). Median duration since diagnosis was four years. Participants with CHD/stroke were older with greater prevalence of smoking, overweight, hypertension and diabetes (p < 0.01). In patients with CHD, stroke and CHD/stroke, respectively, use (%) of antiplatelets was 11.6, 3.8 and 9.3, beta-blockers 11.9, 7.0 and 10.4, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 6.4, 1.9 and 5.3 and statins 4.8, 0.6 and 3.5. In CHD/stroke patients any one of these drugs was used in 18.1%, any two in 7.2%, any three in 2.8% and none in 81.5%. Details of drug dose were not available. Use of drugs was significantly lower in rural low education and low wealth index participants (all p < 0.01). Low wealth index participants had the lowest use of these therapies with no attenuation after multiple adjustments.. The use of secondary preventive drug therapies in patients with known CHD or stroke in South Asia is low with over 80% receiving none of the effective drug treatments. Low household wealth is the most important determinant.

Topics: Adult; Aged; Bangladesh; Cardiovascular Agents; Comorbidity; Coronary Disease; Developing Countries; Drug Costs; Educational Status; Female; Humans; Income; India; Linear Models; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Pakistan; Poverty; Prospective Studies; Residence Characteristics; Risk Factors; Rural Health Services; Secondary Prevention; Socioeconomic Factors; Stroke; Treatment Outcome; Urban Health Services

Previous cross-sectional surveys in different European countries within the EUROASPIRE programme demonstrated a high prevalence of modifiable risk factors, unhealthy lifestyles and inadequate drug treatment in coronary heart disease patients. Comparable data for ischaemic stroke patients is lacking.. A stroke-specific study module was added to the EUROASPIRE III core survey. This cross-sectional multicentre survey included consecutive patients with first-ever ischaemic stroke from four European countries. Data were obtained from medical records, patient interviews and patient examinations within 6-36 months after the stroke event. Control of modifiable risk factors after stroke was evaluated against contemporary European guidelines.. A total of 881 patients was recruited. Median age was 66 years, 37.5% were female; average time from the stroke event to interview was 550 days. At the time of the interview, 17.6% of stroke patients smoked cigarettes, 35.5% had a body mass index ≥30 kg/m(2), 62.4% showed elevated blood pressure and 75.7% exhibited elevated LDL cholesterol levels. Antiplatelet drugs or oral anticoagulants were used by 87.2%, antihypertensive medication by 84.4% and statins by 56.8% of stroke patients. Among patients using antihypertensive drugs and lipid-lowering medication at the time of the interview, 34.3% and 34.4%, respectively, achieved target blood pressure and total cholesterol values according to current European guidelines.. The EUROASPIRE III stroke-specific module shows that secondary prevention and risk factor control in patients after ischaemic stroke need to be improved in four European centres at the time of the study since about half of patients are not achieving risk factor targets defined in European guidelines.

Topics: Aged; Brain Ischemia; Cardiovascular Agents; Comorbidity; Cross-Sectional Studies; Delivery of Health Care; Europe; Female; Guideline Adherence; Health Care Surveys; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Life Style; Male; Middle Aged; Practice Guidelines as Topic; Prevalence; Recurrence; Risk Assessment; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Smoking; Smoking Cessation; Smoking Prevention; Stroke; Surveys and Questionnaires; Time Factors; Treatment Outcome; Weight Loss

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone.. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period.. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65).. CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Topics: Age Factors; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Diagnostic Imaging; Disease Progression; Disease-Free Survival; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Patient Selection; Recurrence; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Atrial fibrillation (AF) is a common cardiovascular morbidity, not least among elderly people, and is treated with different classes of cardiovascular pharmacotherapies.. Cardiovascular drugs may have a different impact on survival in elderly patients with AF in primary health care.. A cohort of 3,020 men and 3,749 women aged ≥75 and diagnosed with AF were selected from 75 primary care centres in Sweden. Laplace regression was used with years to death of the first 10% of the participants as the outcome. Independent variables were prescribed cardiovascular drugs. Regression models were adjusted for a propensity score comprising age, cardiovascular co-morbidities, socio-economic factors and other cardiovascular pharmacotherapies.. Overall, mortality was 18.2%. The main finding of this study was survival increases associated with anticoagulants versus no treatment and versus antiplatelets of 1.95 years (95% confidence interval (CI) 1.43-2.48) and 0.78 years (95% CI 0.38-1.18), respectively, and survival increases associated with thiazides and calcium channel blockers of 0.81 years (95% CI 0.43-1.18) and 0.83 years (95% CI 0.47-1.18), respectively, in men and women together (results from sex-adjusted models).. Our findings suggest that anticoagulants, thiazides and calcium channel blockers may lead to longer survival in elderly patients with AF.

Topics: Age Factors; Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Calcium Channel Blockers; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Diuretics; Female; Geriatric Assessment; Humans; Male; Propensity Score; Regression Analysis; Risk Assessment; Risk Factors; Sex Factors; Socioeconomic Factors; Stroke; Sweden; Time Factors; Treatment Outcome

Several guidelines recommend carotid endarterectomy for patients with severe asymptomatic carotid stenosis to reduce the risk of a future cerebrovascular event, as long as the perioperative stroke/death rate is <3%. Based on improvements in best medical treatment, it was argued that currently best medical treatment alone should comprise the treatment-of-choice for asymptomatic carotid stenosis patients and that no intervention is warranted in these individuals. While it is true that best medical treatment should be used for the management of all asymptomatic carotid stenosis patients, emerging evidence suggests that best medical treatment alone may not prevent disease progression and the development of symptoms in some asymptomatic carotid stenosis patient subgroups. This article analyzes the results of two recent independent studies demonstrating that medical therapy alone may not be adequate for stroke prevention in some asymptomatic carotid stenosis patient subgroups. These results suggest that besides best medical treatment, additional carotid endarterectomy should be considered for specific asymptomatic carotid stenosis patients.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Combined Modality Therapy; Disease Progression; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

The difference between left atrial (LA) and systemic coagulation activity in paroxysmal atrial fibrillation (PAF) is unclear.. We enrolled 100 patients with PAF who underwent AF ablation. Warfarin was stopped 1 day before the procedure. LA volume index and LA emptying fraction were measured by 64-slice multidetector computed tomography. Immediately after transseptal puncture, blood samples were simultaneously collected from the LA and systemic circulation (SC). In addition, to evaluate the effect of warfarin on D-dimer levels we recruited an additional 27 PAF patients on continuous warfarin. Even in patients with low CHADS2 scores (mean 0.59 ± 0.68) and during sinus rhythm, the prevalence of positive LA-D-dimer (≥ 0.5 µg/ml) was greater than that of SC-D-dimer (23% vs. 10%, P<0.01). The LA-D-dimer-positive patients had a larger mean LA volume index and reduced LA emptying fraction than the LA-D-dimer-negative patients. Multiple logistic regression analysis revealed that LA volume index was independently correlated with positive LA-D-dimer (odds ratio 2.245, 95% confidence interval 1.194-4.626, P=0.0112). The prevalence of positive LA-D-dimer was significantly lower in patients taking continuous warfarin, than in those on discontinuous warfarin (3.7% vs. 23%, P=0.025).. An enlarged LA volume index was associated with high LA coagulation status in patients with paroxysmal AF. Adequate warfarin control during AF catheter ablation may reduce the prevalence of positive LA-D-dimer.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Comorbidity; Diabetes Mellitus; Female; Fibrin Fibrinogen Degradation Products; Heart Atria; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Multidetector Computed Tomography; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Prospective Studies; Prothrombin Time; Severity of Illness Index; Stroke; Thrombophilia; Thrombosis; Ultrasonography; Warfarin

To develop an economic model to estimate the change in the number of events and costs of non-fatal myocardial infarction (MI) and non-fatal ischemic stroke (IS) as a result of implementing routine risk-stratification with a multiple inflammatory biomarker approach.. Reductions in the numbers of non-fatal MI and non-fatal IS events and in related per-member-per-month (PMPM) and 5-year costs (excluding test costs) due to biomarker testing were modeled for a US health plan with one million beneficiaries. Inputs for the model included literature-based MI and IS incidence rates, healthcare costs associated with MI and IS, laboratory results of biomarker testing, MI and IS hazard ratios related to biomarker levels, patient monitoring and intervention costs and use/costs of preventative pharmacotherapy. Preventative pharmacotherapy inputs were based on an analysis of pharmacy claims data. Costs savings (2013 USD) were assessed for patients undergoing biomarker testing compared to the standard of care. Data from MDVIP and Cleveland Heart Lab supported two critical inputs: (1) treatment success rates and (2) the population distribution of biomarker testing. Incidence rates, hazard ratios, and other healthcare costs were obtained from the literature.. For a health plan with one million members, an estimated 21,104 MI and 22,589 IS events occurred in a 5-year period. Routine biomarker testing among a sub-group of beneficiaries ≥35 years old reduced non-fatal MI and IS events by 2039 and 1869, respectively, yielding cost savings of over $187 million over 5 years ($3.13 PMPM), excluding test costs. Results were sensitive to changes in treatment response rates. Nonetheless, cost savings were observed for all input values.. This study suggests that health plans can realize substantial cost savings by preventing non-fatal MI and IS events after implementation of routine biomarker testing. Five-year cost savings before test costs could exceed $3.13 PMPM.

Topics: 1-Alkyl-2-acetylglycerophosphocholine Esterase; Adult; Age Factors; Aged; Aged, 80 and over; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Cardiovascular Diseases; Costs and Cost Analysis; Female; Hematologic Tests; Humans; Insurance Claim Review; Male; Middle Aged; Models, Econometric; Myocardial Infarction; Peroxidase; Risk Assessment; Risk Factors; Stroke; United States

There is evidence and international consensus on the advantages and potential of a polypill for established cardiovascular disease patients to improve adherence in the secondary prevention of cardiovascular disease. This study aimed to estimate the numbers of stroke patients who would be eligible for the polypill strategy in China, and the suitable composition of a polypill, based on data of the China National Stroke Prevention Project.. A total of 717 620 residents aged ≥40 years from 6 Chinese representative provinces were screened for prevalent stroke from 2011 to 2012 with an 84.4% response rate. Participants with a history of stroke received further investigation of risk factors and treatments. The potential need for treatment was classified according to the guidelines. Rates were standardized using the population composition of the Sixth National Population Census of China.. The standardized prevalence rate of stroke was 1.9%. Up to 93.1% of stroke patients were eligible for a polypill containing at least 2 types of medications, with 75.3% eligible for a statin and antiplatelet agent and 70.6% for antihypertensive and antiplatelet medications. Considering 3 therapies, 54% were eligible for antihypertensive, statin, and antiplatelet medications. The current treatment rate with all required combinations of separate pills was only 6.9%.. A huge number of stroke patients in China require preventive therapy and would be eligible for a polypill. This study indicates that it would be reasonable to consider and assess the value of a polypill strategy to improve secondary prevention of stroke in China.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Antihypertensive Agents; Blood Pressure; Cardiovascular Agents; Cardiovascular Diseases; China; Drug Combinations; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Risk Factors; Secondary Prevention; Socioeconomic Factors; Stroke

Studies evaluating long-term (≥5 years) outcome of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with unprotected left main coronary artery disease (ULMCAD) are still limited, despite concerns for late adverse events after drug-eluting stents implantation.. We identified 1,004 patients with ULMCAD (PCI: n=364, CABG: n=640) among 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG registry cohort-2. The primary outcome measure in the current analysis was a composite of death, myocardial infarction, and stroke (death/MI/stroke). The cumulative 5-year incidence of and the adjusted risk for death/MI/stroke were significantly higher in the PCI group than in the CABG group (34.5% vs. 24.1%, log-rank P<0.001, adjusted hazard ratio (HR): 1.48 [95% confidence interval (CI): 1.07-2.05, P=0.02]). The adjusted risks for all-cause death was not significantly different between the 2 groups. Regarding the stratified analysis by the SYNTAX score, the adjusted risk for death/MI/stroke was not significantly different between the 2 groups in patients with low (<23) or intermediate (23-33) SYNTAX score, whereas it was significantly higher in the PCI group than in the CABG group in patients with high (≤33) SYNTAX score.. CABG as compared with PCI was associated with better long-term outcome in patients with ULMCAD, especially those with high anatomical complexity.

Topics: Cardiovascular Agents; Cause of Death; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass; Coronary Disease; Death, Sudden, Cardiac; Follow-Up Studies; Humans; Japan; Kaplan-Meier Estimate; Mortality; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Risk; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Bayesian meta-analysis is an increasingly important component of clinical research, with multivariate meta-analysis a promising tool for studies with multiple endpoints. Model assumptions, including the choice of priors, are crucial aspects of multivariate Bayesian meta-analysis (MBMA) models. In a given model, two different prior distributions can lead to different inferences about a particular parameter. A simulation study was performed in which the impact of families of prior distributions for the covariance matrix of a multivariate normal random effects MBMA model was analyzed. Inferences about effect sizes were not particularly sensitive to prior choice, but the related covariance estimates were. A few families of prior distributions with small relative biases, tight mean squared errors, and close to nominal coverage for the effect size estimates were identified. Our results demonstrate the need for sensitivity analysis and suggest some guidelines for choosing prior distributions in this class of problems. The MBMA models proposed here are illustrated in a small meta-analysis example from the periodontal field and a medium meta-analysis from the study of stroke. Copyright © 2015 John Wiley & Sons, Ltd.

Topics: Algorithms; Bayes Theorem; Biostatistics; Cardiovascular Agents; Computer Simulation; Humans; Meta-Analysis as Topic; Models, Statistical; Multivariate Analysis; Periodontal Diseases; Randomized Controlled Trials as Topic; Stroke

The cardiovascular burden and consequences of peripheral atherosclerosis appear to differ between men and women. Data regarding long-term outcomes, including the impact of medical prophylactic treatment, are insufficient. This study examined long-term outcomes according to sex following primary vascular surgery, adjusted for multiple variables as well as recommended medical prophylaxis.. All Danish patients who underwent peripheral vascular surgery from January 2000 to December 2007 were stratified into five procedural groups: (a) aorto-iliac bypass or thromboendarterectomy, (b) femoro-femoral crossover, (c) thromboendarterectomy of the femoral arteries, (d) infrainguinal bypass, or (e) axillo- uni-, and bifemoral bypass. Data were analyzed according to sex for differences in myocardial infarction, stroke, and death, individually and combined, after surgery.. A total of 11,234 patients were included: 6,289 males and 4,945 females. The overall adjusted hazard ratio for male patients compared with female patients for death was 1.11 (95% CI 1.06-1.17), for MI was 1.16 (95% CI 1.04-1.29), for stroke was 0.99 (95% CI 0.89-1.11), and for any major adverse cardiovascular event was 1.10 (95% CI 1.05-1.16).. These findings show that, despite indication, severity, and concomitant medical treatment of peripheral artery disease, men have a higher risk of mortality and adverse cardiovascular events following surgery for peripheral arterial disease.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cause of Death; Comorbidity; Denmark; Female; Health Status Disparities; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Peripheral Arterial Disease; Registries; Retrospective Studies; Risk Factors; Severity of Illness Index; Sex Factors; Stroke; Time Factors; Treatment Outcome; Vascular Surgical Procedures

Topics: Cardiovascular Agents; Female; Health Status Disparities; Humans; Male; Myocardial Infarction; Peripheral Arterial Disease; Stroke; Vascular Surgical Procedures

Little is known about whether enrollment versus nonenrollment in Medicare's prescription drug plan (Part D) is associated with better outcomes after acute myocardial infarction (AMI).. Using Medicare records linked to Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines, we identified 59 149 Medicare beneficiaries (age ≥65 years) discharged after AMI between January 2007 and December 2010. We described trends in Medicare Part D enrollment, and compared the following 30-day and 1-year outcomes: all-cause death, all-cause readmissions, and major adverse cardiac events (a composite of all-cause death or readmission for AMI or stroke) between Part D enrollees and nonenrollees, after adjustment for patient and hospital factors. From 2007 to 2010, 29 264 (49.5%) patients with AMI enrolled in Medicare were also participating in Part D by hospital discharge. All-cause 30-day death was more common among enrollees versus nonenrollees (4.0% versus 3.3%), but this difference was not statistically significant after multivariable adjustment (adjusted hazard ratio, 1.06 [95% confidence interval, 0.97-1.17]). Enrollees also had higher unadjusted risks of 30-day all-cause readmissions or major adverse cardiac events, and 1-year mortality, all-cause readmissions, or major adverse cardiac events, but these were attenuated after multivariable adjustment. Adherence to key secondary prevention medications (statins, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and P2Y12 antagonists) remained low (range, 55%-64%) at 1 year post discharge among Part D enrollees.. Only half of Medicare-insured patients with AMI were enrolled in Part D by hospital discharge, and their 30-day and 1-year adjusted outcomes did not differ substantially from nonenrollees. There remain opportunities for improvement in medication adherence among patients with prescription drug coverage.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Electronic Health Records; Female; Humans; Insurance Benefits; Male; Medical Record Linkage; Medicare Part D; Medication Adherence; Myocardial Infarction; Patient Discharge; Patient Readmission; Recurrence; Registries; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome; United States

We sought to evaluate the prognosis of different treatment strategies on patients with multivessel coronary disease and high SYNTAX score. 171 patients with multivessel coronary disease and SYNTAX score ε33, who underwent coronary angiography between July 2009 and July 2010 at our hospital were retrospectively selected and divided into incomplete and complete revascularization intervention groups (IR), a coronary artery bypass surgery group (CABG), a conservative drug therapy group according to treatment strategies chosen and agreed by the patients. These patients were followed up for 19.44 ± 5.73 months by telephone or outpatient service. We found the medical treatment group has a lower overall survival than the IR, CR group, and CABG group (P log-rank values are 0.03, 0.03, and 0.02, respectively). The medical treatment group also has a lower survival than the IR group, CR group, and CABG group in cerebral stroke and recurrent myocardial infarction (MI) (P log-rank values are 0.004, 0.03, and 0.001, respectively) and MACE events (P log-rank values are 0.003, 0.001 and P < 0.001, respectively). The medical treatment group and IR group have lower survival in recurrent angina pectoris than the CR group and CABG group (P log-rank values are 0.02, 0.02 and 0.03, 0.008, respectively). There are no significant differences between the CR group and the CABG group in number of deaths, strokes and recurrent MIs, MACE events, angina pectoris (P log-rank values are 0.69, 0.53, and 0.86, respectively). The IR group shows a lower survival than the CR group and CABG group only in angina pectoris (P log-rank values are 0.03 and 0.008, respectively). For the patients with a high SYNTAX score, medical treatment is still inferior to revascularization therapy (interventional therapy or coronary artery bypass surgery). It appears that the CABG is not obviously superior to the coronary intervention therapy. Complete revascularization and coronary artery bypass grafting treatments simply have better survival in angina pectoris compared to the incomplete revascularization. Therefore, individual treatment strategies are recommended and more trials are required to study these effects.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Stroke; Survival Analysis

Topics: Cardiovascular Agents; Coronary Disease; Exercise Therapy; Female; Heart Failure; Humans; Hypoglycemic Agents; Male; Prediabetic State; Stroke

Although level 1 evidence supports carotid endarterectomy (CEA) for stroke prevention in patients with asymptomatic severe carotid artery stenosis (ASCAS; >70%), medical therapy alone has been promulgated by some as equally effective. The goal of this study was to determine the natural history of medically treated patients with ASCAS.. Patients with ASCAS from 2005 to 2006 were identified in a health network database. Patients were included if the initial therapeutic plan involved medical therapy alone (usually because of comorbidities or patient preference). Study end points included: ipsilateral neurologic symptoms (INS) of transient ischemic attack and/or stroke, death, and INS and/or death.. There were 126 carotid arteries identified in 115 patients. Using standard duplex velocity criteria, 88 (70%) had severe (70%-89%) and 38 (30%) had very severe stenoses (VSS; 90%-99%). The average age was 73.5 years, demographic characteristics included: 66% hypertension, 64% coronary artery disease, 30% diabetes, 5% chronic kidney disease (CKD), and 86% were taking a statin drug (28% had a low-density lipoprotein level <100 mg/dL). There were 31 patients (24.6%) who developed INS during a mean follow-up of 27 months; most (23 of 31; 74%) occurred within 12 months of the initial duplex ultrasound examination; 14 (45%) were strokes. The 5-year actuarial freedom from INS was 70.1 ± 5%. Multivariate predictors of INS included: VSS (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.56-6.76; P = .002), CKD (HR, 6.25; 95% CI, 2.05-19.2; P = .001), and age (HR, 0.94; 95% CI, 0.91-0.98; P = .001). There were 41 patients (33%) who underwent eventual carotid revascularization (32 CEA, nine stent); 23 of 41 (56%) were performed for INS and 18 (44%) for plaque progression. Overall 5-year actuarial survival was 69.8% ± 4.1%. Multivariate predictors of death included: age (HR, 1.06; 95% CI, 1.03-1.1; P = .0001), chronic obstructive pulmonary disease (HR, 1.92; 95% CI, 1.08-3.41; P = .03), and diabetes (HR, 5.08; 95% CI, 2.86-9.01; P < .0001). The 5-year actuarial freedom from INS and/or death was 54 ± 4.4%. Multivariate predictors of INS and/or death were: VSS (HR, 1.98; 95% CI, 1.22-3.23; P = .006), CKD (HR, 5.46; 95% CI, 2.12-14.08; P = .0004), and diabetes (HR, 2.6; 95% CI, 1.59-4.24; P = .0001). Statin use was not protective against INS or death in this cohort.. Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.

Topics: Aged; Aspirin; Asymptomatic Diseases; Blood Flow Velocity; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Comorbidity; Disease Progression; Disease-Free Survival; Female; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Registries; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Heart disease is the number one killer of women, and studies have shown connections between cardiovascular and oral health. However, interprofessional community-based participatory initiatives promoting women's oral health have received little research attention. This study evaluated the effectiveness of personalized oral health education (POHE) during a free one-day interprofessional women's health promotion event. The objectives were to 1) assess the participants' knowledge about the connection between oral health and heart disease; 2) disseminate information about oral-systemic linkages; 3) encourage comprehensive dental examinations; and 4) evaluate POHE outcomes. West Virginia University School of Dentistry faculty and students delivered POHE to the participants. These POHE instructors were calibrated with a standardized script regarding periodontal disease, health impact of tobacco, xerostomia-inducing medications, and oral hygiene instruction. Immediately prior to and following each POHE session, all the participants (N=165; 100 percent response rate) completed a number-coded questionnaire. The findings showed that the participants' knowledge of oral-systemic health linkages had increased following the POHE. The respondents received oral health kits and were offered discount vouchers toward the cost of a comprehensive oral examination at the dental school. This replicable model may prove useful to other dental schools in promoting women's oral health.

Topics: Aged; Attitude to Health; Bacteremia; Cardiovascular Agents; Dental Care; Female; Health Education, Dental; Health Fairs; Health Promotion; Heart Diseases; Humans; Information Dissemination; Memory Disorders; Middle Aged; Oral Health; Oral Hygiene; Periodontal Diseases; Precision Medicine; Stroke; Tobacco Products; Women's Health; Wound Healing; Xerostomia

Individuals with unrecognized myocardial infarction (UMI) have similar risks for cardiovascular events and mortality as those with recognized myocardial infarction (RMI). The prevalence of cardioprotective medication use and blood pressure and low-density lipoprotein cholesterol control among individuals with UMI is unknown.. Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who were recruited between May 2004 and October 2007 received baseline twelve-lead electrocardiograms (n = 21,036). Myocardial infarction (MI) status was characterized as no MI, UMI (electrocardiogram abnormalities consistent with MI without self-reported history; n = 949; 4.5%), and RMI (self-reported history of MI; n = 1574; 7.5%).. For participants with no MI, UMI, and RMI, prevalence of use was 38.4%, 44.4%, and 75.7% for aspirin; 18.0%, 25.8%, and 57.2% for beta blockers; 31.7%, 38.7%, and 55.0% for angiotensin converting enzyme inhibitors or angiotensin receptor blockers; and 28.1%, 33.9%, and 64.1% for statins, respectively. Participants with RMI were 35% more likely to have low-density lipoprotein cholesterol < 100 mg/dL than participants with UMI (prevalence ratio = 1.35, 95% confidence interval 1.19-1.52). Blood pressure control (,140/90 mmHg) was similar between RMI and UMI groups (prevalence ratio = 1.03, 95% confidence interval 0.93-1.13).. Although participants with UMI were somewhat more likely to use cardioprotective medications than those with no MI, they were less likely to use cardioprotective medications and to have controlled low-density lipoprotein cholesterol than participants with RMI. Increasing appropriate treatment and risk factor control among individuals with UMI may reduce risk of mortality and future cardiovascular events.

Topics: Aged; Black or African American; Cardiovascular Agents; Cross-Sectional Studies; Drug Utilization; Drug Utilization Review; Electrocardiography; Female; Humans; Male; Middle Aged; Myocardial Infarction; Practice Patterns, Physicians'; Residence Characteristics; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome; United States; White People

This study was carried out to determine the effect of the use of dual antiplatelet therapy (DAPT) for more than 12 months on long-term clinical outcomes in patients who had undergone a percutaneous coronary intervention with the first and second generations of drug-eluting stents (DES).. The potential benefits of the use of DAPT beyond a 12-month period in patients receiving DES have not been established clearly. Moreover, it is also unclear whether the optimal duration of DAPT is similar for all DES types.. A total of 2141 patients with coronary artery disease treated exclusively with Cypher sirolimus-eluting stents (SES) or Endeavor zotarolimus-eluting stents (ZES) were considered for retrospective analysis. The primary endpoint [a composite of all-cause mortality, nonfatal myocardial infarction (MI), and stroke] was compared between the 12-month DAPT and the >12-month DAPT group.. A total of 1870 event-free patients on DAPT at 12 months were identified. The average follow-up was 28.2±7.4 months. The primary outcomes were similar between the two groups (4.1% 12-month DAPT vs. 1.9% >12-month DAPT; P=0.090). Incidences of death, MI, stroke, and target vessel revascularization did not differ significantly between the two groups. Subgroup analysis showed that in the patients with hypertension, >12-month DAPT significantly reduced the occurrence of death/MI/stroke compared with that in the 12-month DAPT group (P=0.04). In patients implanted with SES, the primary outcome was significantly lower with the >12-month DAPT group (5.2% 12-month DAPT vs. 1.6% >12-month DAPT; P=0.016), whereas in patients with ZES, the primary outcome was comparable between the two groups (2.3% 12-month DAPT vs. 2.0% >12-month DAPT; P=0.99).. In our study, for all patients, >12-month DAPT in patients who had received DES was not significantly more effective than 12-month DAPT in reducing the rate of death/MI/stroke. Our findings, that patients who received SES benefit from >12-month DAPT whereas extended use of DAPT was not significantly more effective in those implanted with ZES, implied that the optimal duration of DAPT was different depending on different types of DES.

Topics: Aged; Aspirin; Cardiovascular Agents; Chi-Square Distribution; Clopidogrel; Coronary Artery Disease; Disease-Free Survival; Drug Administration Schedule; Drug Therapy, Combination; Drug-Eluting Stents; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Proportional Hazards Models; Prosthesis Design; Retrospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stroke; Ticlopidine; Time Factors; Treatment Outcome

Studies have shown that aspirin used for secondary prevention significantly reduces cardiovascular and stroke risk. The data for aspirin and primary prevention of cardiovascular disease, and in particular stroke, are less clear, especially among blacks.. To evaluate prophylactic aspirin use and incident stroke in a large cohort of black and white participants.. The Reasons for Geographic and Racial Differences in Stroke study is a national, population-based, longitudinal study of 30,239 African Americans and whites, older than 45 years. Participants with stroke at baseline were excluded, reducing the cohort to 27,219. Proportional hazard models were used to estimate the association of incident stroke with prophylactic aspirin use, adjusted for confounding factors. Separate analyses were performed for subjects who self-reported baseline aspirin use for primary prevention of vascular disease compared with those using aspirin use for other indications.. In all, 10,177 participants taking prophylactic aspirin were followed for a mean of 4.6 years. Univariate analysis showed an increased stroke risk for prophylactic aspirin use (hazard ratio [HR]: 1.37; 95% confidence interval: 1.16-1.62), but the association was attenuated (HR: 1.06; 95% CI: .86-1.32) with multivariable adjustment, adjusting for demographic factors (age, race, sex, and region), socioeconomic factors (income and education), perceived general health, cardiovascular disease (CVD) risk factors (hypertension, diabetes, dyslipidemia, cigarette smoking, and alcohol use), and finally the Framingham Stroke Risk Score (in a separate model). No racial, sex, or regional differences in the association were demonstrated.. In this observational study, prophylactic aspirin use was not associated with risk of first stroke, and there were no sex, race, or regional differences.

Topics: Aged; Aged, 80 and over; Aspirin; Black or African American; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Female; Humans; Incidence; Longitudinal Studies; Male; Middle Aged; Multivariate Analysis; Primary Prevention; Propensity Score; Proportional Hazards Models; Residence Characteristics; Risk Factors; Stroke; United States; White People

Despite level 1 evidence in support of carotid endarterectomy vs medical therapy in selected asymptomatic patients, an alternative posture is that optimal medical therapy (OMT) has not been adequately studied and that such OMT has reduced stroke risk in asymptomatic patients to levels wherein carotid endarterectomy is no longer justified. The goal of this study was to determine the natural history of patients with asymptomatic moderate (50%-69%) carotid artery stenosis (AMCAS) in a contemporary cohort as a function of their associated medical therapy.. Patients with AMCAS determined by duplex ultrasound (DUS) from 2005-2006 were identified in our hospital database. Patients were included in the cohort if they had at least one additional DUS during the 6-year follow-up interval. Patient characteristics including medication history and lipid levels were collected. Patients were considered to have OMT if they were on aspirin and a statin with a low-density lipoprotein level that was always <100 mg/dL. Study end points included progression of carotid disease by DUS to severe stenosis (70%-100%), development of ipsilateral neurologic symptoms (INS) such as stroke or transient ischemic attack, and death.. There were 900 carotid arteries in 794 patients in the study cohort. The average age was 72.5 years, 77.2% had hypertension, 59.6% had coronary artery disease, and 87.1% were on a statin throughout the study. The low-density lipoprotein cholesterol level was always normal (<100 mg/dL) in 37.8% and accordingly, 241 (30.3%) had OMT as defined above. The 5-year actuarial survival was 81.9% ± 1.3% with no advantage seen with OMT. Multivariate analysis of survival showed statins were protective (hazard ratio [HR], 0.50; confidence interval [CI], 0.34-0.73; P = .0004). The 5-year freedom from plaque progression was 61.2% ± 2.1% with no benefit from OMT vs the control group. Multivariate predictors of plaque progression were chronic kidney disease (HR, 2.1; CI, 1.2-3.7; P = .009), aspirin use (HR, 1.9; CI, 1.2-3.0; P = .01), and the use of calcium channel blockers (HR, 1.4; CI, 1.1-1.8; P = .007). There were 90 (11.3%) patients who developed INS during follow-up (58% of these were strokes), and the 5-year freedom from INS was 88.4% ± 1.5%. Multivariate predictors of INS were diabetes (HR, 2.3; CI, 1.5-3.6; P = .0002) and warfarin use (HR, 1.9; CI, 1.2-2.9; P = .009); while statin use (HR, 0.37; CI, 0.22-0.65; P = .0005) was protective against symptom development.. At the 5-year of follow-up, OMT failed to prevent carotid disease progression or development of ipsilateral symptoms in 45% of patients with AMCAS.

Topics: Aged; Aged, 80 and over; Aspirin; Asymptomatic Diseases; Biomarkers; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Cholesterol, LDL; Comorbidity; Disease Progression; Drug Therapy, Combination; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

Topics: Atrial Fibrillation; Cardiovascular Agents; Female; Heart Rate; Humans; Ischemic Attack, Transient; Male; Stroke

There is a dilemma in modern medicine, and, as a general family practitioner, this dilemma has great impact on me as a professional with a responsibility to my patients, and on the treatments I prescribe. Every day we receive a lot of updated information about relevant issues in treatment of various conditions we encounter in our daily practice. There is a great deal of interesting, serious research; however, frequently results and conclusions are very different and at times, contradictory. It is extremely difficult to evaluate updated research information, and to understand trends in current medicine. Our responsibility to our patients is to find a solution for this problem.

Topics: Aspirin; Biomedical Research; Cardiovascular Agents; Evidence-Based Medicine; Family Practice; Guidelines as Topic; Humans; Myocardial Infarction; Practice Patterns, Physicians'; Stroke; Uncertainty

To assess long-term outcome after rotational atherectomy (RA) is followed by drug-eluting stent (DES) implantation in complex calcified coronary lesions.. RA can favorably modify heavily calcified coronary lesions, but long-term outcome is poor when it is used as a stand-alone therapy or combined with bare-metal stents. DES have reduced rates of restenosis in a wide range of patient and lesion subsets, but little information is available on long-term clinical outcome when RA is followed by DES implantation (Rota-DES) in complex calcified lesions.. Two hundred and five patients with de novo complex calcified coronary lesions treated with Rota-DES were analyzed. Mean age was 69.7 ± 9.3 years, 63 patients (31%) had diabetes mellitus and 21 patients (10%) had chronic renal failure. Total stent length/patient was 32 mm. The majority of patients were treated with paclitaxel-eluting stents (64%) or sirolimus-eluting stents (30%). Angiographic success rate was 98%. The incidence of in-hospital major adverse cardiac events (MACE), defined as death, myocardial infarction (MI), and target vessel revascularization (TVR), was 4.4%. Long-term follow-up was available for 188 patients (92%). At a median follow-up period of 15 months (range, 1-84), the cumulative incidence of MACE (Kaplan-Meier estimate) was 17.7%. Death occurred in 4.4%, MI in 3.4%, TVR in 9.9%, and target lesion revascularization (TLR) in 6.8%. One definite (0.5%) and one probable (0.5%) stent thrombosis were observed. In a multivariate analysis, low ejection fraction (<40%) was the only independent predictor of MACE, and both age and diabetes were independent predictors of TLR.. This study represents the largest European data set of patients treated with RA in the DES era. RA followed by DES implantation in calcified coronary lesions appears to be feasible and effective, with a high rate of procedural success and low incidence of TLR and MACE at long term considering this complex patient and lesion subset.

Topics: Aged; Aged, 80 and over; Atherectomy, Coronary; Cardiovascular Agents; Comorbidity; Coronary Angiography; Coronary Artery Disease; Diabetes Mellitus; Drug-Eluting Stents; Female; Hospital Mortality; Humans; Incidence; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Paclitaxel; Percutaneous Coronary Intervention; Proportional Hazards Models; Prosthesis Design; Registries; Retrospective Studies; Risk Factors; Sirolimus; Stroke; Thrombosis; Time Factors; Treatment Outcome; Vascular Calcification

No information exists, to our knowledge, about the possible role of cardiovascular drug administration in the acute phase of ischemic stroke and possible effects on stroke outcome. The aim of our study was to evaluate the relationship between in-hospital treatment with cardiovascular drugs in patients with acute ischemic stroke and some outcome indicators.. 1096 subjects enrolled in the GIFA study, who had a main discharge diagnosis of ischemic stroke represent the final sample. Drugs considered for the analysis were the following: ACE-inhibitors (ACEI), angiotensin II receptor blockers (ARBs), statins, calcium-channel-blockers (CCBs), antiplatelet (APL) drugs, antivitamin-k (VKAs), and heparins. As outcome indicators we choose in-hospital mortality, cognitive function evaluated by Hodkinson Abbreviated Mental Test (HAMT), and functional status evaluated by activity daily living (ADL). Indicators of a good outcome were: no in-hospital mortality, HAMT >6 and 0 ADL impaired. Patients with a good outcome showed a higher rate of in-hospital treatment with ACE-inhibitors, calcium-channel blockers and a lower rate of pre-treatment with heparin.. Our study suggests that if a patient with acute ischemic stroke has higher SBP at admission, higher total cholesterol plasma levels, a lower Charlson index and is treated with ACE-inhibitors, calcium channel blockers and antiplatelet drugs, the short term outcome is better in terms of in-hospital mortality and functional indicators such as cognitive and functional performance at discharge.

Topics: Activities of Daily Living; Aged; Angiotensin-Converting Enzyme Inhibitors; Brain Ischemia; Calcium Channel Blockers; Cardiovascular Agents; Cognition Disorders; Comorbidity; Female; Geriatric Assessment; Humans; Hypercholesterolemia; Hypertension; Italy; Male; Platelet Aggregation Inhibitors; Prognosis; Retrospective Studies; Stroke; Time Factors

This study evaluates comorbidities, primary and secondary drug prevention and two years survival among patients hospitalized for stroke during the first half of 2008.. First hospitalization with stroke diagnosis was identified by using the national hospital discharge database and linked to the reimbursement database of the beneficiaries covered by the general health insurance scheme (74% of the 64 million population). A medication was considered to be used when there were more than two reimbursements over the 6 months following or preceding hospitalization.. Among the 36,844 patients with stroke, 31.6% had a main diagnosis of transient ischemic attack (TIA), 53.6% a cerebral infarct (CI) and 14.8% a cerebral hemorrhage (CH). For the 8429 patients aged less than 60 years, high frequency of low-income and full health insurance coverage (11% of the covered population) was found for CI (17.6%) and CH (24.6%). Specific refund for invalidating stroke before hospitalization was found for 16% of patients with CI and 10.5% of those with CH. During the two previous years, around 7% of all patients were hospitalized for stroke, 30% for arterial hypertension, 13% for cardiac electric disorders, 10% for coronary disease and 12% for diabetes. Death rates one month after hospitalization were 11.3% for CI and 33.8% for CH, and two years after 22.5% for CI, 43% for CH and 7.7% for TIA. At least one antihypertensive drug treatment was found for 55.2% of patients with a TIA before hospitalization and 62.9% after and respectively 59.4% and 65.8% for CI and 51.1% and 57.7% for CH. Before hospitalization, beta-blocker was the most frequent antihypertensive class (21 to 25.6% according to stroke type). After hospitalization, frequency increased for angiotensin-converting enzyme inhibitors among CI patients (31% vs. 18.7%) and calcium-channel blockers among CH patients (27.1% vs. 13.7%). Antiplatelet drugs were used by 58% of the patients with CI after hospitalization (27.8% before). An anticoagulant drug was present for 74.8% of patients with CI, 69.5% for TIA and 19.2% for CH. Among patients with ischemic stroke, half of them had a lipid-lowering drug after hospitalization. A combination of antihypertensive, anticoagulant and lipid lowering drugs was found for 32.9% of patients with a TIA, 39.9% for CI and 7.6% for CH after hospitalization.. These patients presented frequently a history of stroke and comorbidities and their level of secondary prevention must be improved.

Topics: Adult; Aged; Aged, 80 and over; Antihypertensive Agents; Cardiovascular Agents; Comorbidity; Drug Utilization; Female; Fibrinolytic Agents; France; Hospital Mortality; Hospitals, General; Humans; Hypoglycemic Agents; Hypolipidemic Agents; Inpatients; Kaplan-Meier Estimate; Male; Middle Aged; Patient Readmission; Psychotropic Drugs; Risk Factors; Secondary Prevention; Stroke; Young Adult

The biodegradable polymer drug-eluting stents have been proposed as an alternative to durable polymer DES, theoretically improving vessel healing and reducing the need for prolonged double anti platelet therapy (DAPT), however clinical significance of this technology is under debate. Therefore, we sought to compare the clinical outcomes of two Paclitaxel eluting stents (PES) containing different polymer-based eluting matrices.. In this multicenter registry of 392 consecutive patients who underwent PCI between June 2006 and September 2008, we included patients with stable angina or NSTE-ACS displaying at least one significant lesion (>50% diameter stenosis) in native coronary arteries.. Biodegradable polymer PES (BP-PES, LUC Chopin(2) , Balton, Poland) was implanted in 206 patients, whereas durable polymer PES (DP-PES, Taxus, Boston Scientific, USA) was implanted in 186 patients. There were no significant differences in baseline characteristics between groups with the exception of increased diabetes and number of lesions for BP-PES. In risk-unadjusted analysis at 1-year follow-up, there were no significant differences in TLR (BP-PES: 8.4% vs.. 6%; P = 0.36), TVR (BP-PES: 11.1% vs.. 8.4%; P = 0.36) and incidence of stent thromboses (BP-PES: 2.15% vs.. 3.4%; P = 0.42) between groups. There was also no difference in MACCE between groups (17.6% vs. 14.4%, P = 0.49). The mean dual antiplatelet therapy (DAPT) compliance at 1 year was 77% for BP-PES versus 92% for DP-PES (P = 0.03). Kaplan-Meier analysis showed a significantly higher long-term stroke free survival in BP-PES (P = 0.04). After adjustment, this was sustained with an additional tendency toward higher MI free survival for BP-PES (P = 0.059).. In this observational analysis, BP-PES were comparable to DP-PES, with regard to incidence of repeated revascularizations, stent thromboses and MACCE despite earlier DAPT discontinuation.

Topics: Absorbable Implants; Acute Coronary Syndrome; Aged; Angina, Stable; Cardiovascular Agents; Coronary Stenosis; Coronary Thrombosis; Disease-Free Survival; Drug Administration Schedule; Drug Therapy, Combination; Drug-Eluting Stents; Female; Humans; Incidence; Kaplan-Meier Estimate; Male; Medication Adherence; Middle Aged; Myocardial Infarction; Paclitaxel; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Poland; Polymers; Propensity Score; Prosthesis Design; Registries; Retrospective Studies; Risk Factors; Stroke; Time Factors; Treatment Outcome

Multivariate meta-analysis allows the joint synthesis of effect estimates based on multiple outcomes from multiple studies, accounting for the potential correlations among them. However, standard methods for multivariate meta-analysis for multiple outcomes are restricted to problems where the within-study correlation is known or where individual participant data are available. This paper proposes an approach to approximating the within-study covariances based on information about likely correlations between underlying outcomes. We developed methods for both continuous and dichotomous data and for combinations of the two types. An application to a meta-analysis of treatments for stroke illustrates the use of the approximated covariance in multivariate meta-analysis with correlated outcomes.

Topics: Biostatistics; Cardiovascular Agents; Humans; Meta-Analysis as Topic; Models, Statistical; Multivariate Analysis; Odds Ratio; Randomized Controlled Trials as Topic; Stroke; Treatment Outcome

Evidence for cardioprotective effects of lycopene is inconsistent. Studies of circulating lycopene generally report inverse associations with CVD risk, but studies based on lycopene intake do not. The failure of dietary studies to support the findings based on biomarkers may be due in part to misclassification of lycopene intakes. To address this potential misclassification, we used repeated measures of intake obtained over 10 years to characterise the relationship between lycopene intake and the incidence of CVD (n 314), CHD (n 171) and stroke (n 99) in the Framingham Offspring Study. Hazard ratios (HR) for incident outcomes were derived from Cox proportional hazards regression models using logarithmically transformed lycopene intake adjusted for CVD risk factors and correlates of lycopene intake. HR were interpreted as the increased risk for a 2·7-fold difference in lycopene intake, a difference approximately equal to its interquartile range. Using an average of three intake measures with a 9-year follow-up, lycopene intake was inversely associated with CVD incidence (HR 0·83, 95% CI 0·70, 0·98). Using an average of two intake measures and 11 years of follow-up, lycopene intake was inversely associated with CHD incidence (HR 0·74, 95% CI 0·58, 0·94). Lycopene intake was unrelated to stroke incidence. The present study of lycopene intake and CVD provides supporting evidence for an inverse association between lycopene and CVD risk; however, additional research is needed to determine whether lycopene or other components of tomatoes, the major dietary source of lycopene, are responsible for the observed association.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Carotenoids; Coronary Disease; Diet; Energy Intake; Female; Humans; Incidence; Lycopene; Male; Middle Aged; Phytotherapy; Plant Extracts; Proportional Hazards Models; Solanum lycopersicum; Stroke

There has been a recent growth in developments of multivariate meta-analysis. We extend the methodology of Bayesian multivariate meta-analysis to the situation when there are more than two outcomes of interest, which is underexplored in the current literature. Our objective is to meta-analyse summary data from multiple outcomes simultaneously, accounting for potential dependencies among the data. One common issue is that studies do not all report all of the outcomes of interests, and we take an approach relying on marginal modelling of only the reported data. We employ a separation prior for the between-study variance-covariance matrix, which offers an improvement on the conventional inverse-Wishart prior, showing robustness in estimation and flexibility in incorporating prior information. Particular challenges arise when the number of outcomes is large relative to the number of studies because the number of parameters in the variance-covariance matrix can become substantial and there can be very little information with which to estimate between-study correlation coefficients. We explore assumptions that reduce the number of parameters in this matrix, including assumptions of homogenous variances, homogenous correlations for certain outcomes and positive correlation coefficients. We illustrate the methods with an example data set from the Cochrane Database of Systematic Reviews.

Topics: Bayes Theorem; Biostatistics; Cardiovascular Agents; Humans; Meta-Analysis as Topic; Models, Statistical; Multivariate Analysis; Outcome Assessment, Health Care; Stroke; Treatment Outcome

Second-generation drug-eluting stents (DES) have provided better results over both bare-metal stents and first-generation DES. However, comparative data of different first- and second-generation DES in a clinical setting of all-comers have not been well studied.. Baseline clinical and angiographic characteristics and in-hospital and follow-up events were recorded for enrolled patients. The composite of death, myocardial infarction, and stroke, defined as major adverse cardiac and cerebrovascular events (MACCE), as well as target vessel revascularization (TVR) was used as the primary end point. Between May 2007 and May 2009, 10,852 patients subjected to drug-eluting stent implantation were enrolled at 74 sites. 3,032 patients (27.9 %) were treated with Taxus™, 4,382 (40.4 %) with Cypher™, 1,012 (9.3 %) with Endeavor™, 1,693 (15.6 %) with Xience V™ and 733 (6.8 %) with Promus™ during this period. At 1-year follow-up, the comparison between groups revealed no significant differences with respect to overall death, MACCE, definite stent thrombosis, TVR, stroke and major bleeding. After adjustment for risk factors in final regression models, a modestly significant association of DES type to MACCE was observed (p = 0.046); however, this association could not be attributed to one particular DES. An impact of DES type on TVR was not seen after risk adjustment.. Data generated from the prospective German drug-eluting stent (DES.DE) registry confirm that safety and efficacy of different first- and second-generation DES are clinically equivalent in the first year of follow-up, even in a more complex setting.

Topics: Aged; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Drug-Eluting Stents; Female; Germany; Hemorrhage; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Stroke; Thrombosis; Time Factors; Treatment Outcome

Topics: Angioplasty, Balloon; Brain; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Endarterectomy, Carotid; Humans; Stroke

The vast majority of reports describing beating heart robotic myocardial revascularization (total endoscopic coronary artery bypass) contain very small numbers of patients undergoing single-vessel bypass. We present a large series of patients undergoing multivessel total endoscopic coronary artery bypass.. We performed a retrospective clinical review of 106 patients undergoing total endoscopic coronary artery bypass (72% multivessel) at 1 institution by 1 experienced cardiac surgeon/physician assistant team. These results were compared with the expected clinical outcomes from conventional coronary artery bypass grafting calculated using the Society of Thoracic Surgeons risk calculator.. Of the 106 patients, 1% underwent quadruple total endoscopic coronary artery bypass, 8% triple, 63% double, and 28% single. The emergent conversion rate for hemodynamic instability was 6.6%. The postoperative renal failure rate (doubling of baseline serum creatinine or dialysis required) was 7.5%. Overall, 23 patients (21.7%) exhibited at least 1 major morbidity/mortality (4 deaths). The number of vessels bypassed (single/double/triple/quadruple) correlated positively with the surgical/operating room time, the lung separation time, vasoactive medication use, blood use, a postoperative ventilation time longer than 24 hours, intensive care unit length of stay, and hospital length of stay. An increased surgical time was significantly associated with major morbidity (P = .011) and mortality (P = .043). A comparison with the Society for Thoracic Surgeons expected outcomes revealed a similar hospital length of stay but an increased incidence of prolonged ventilation (P = .003), renal failure (P < .001), morbidity (P = .045), and mortality (P = .049).. Our results suggest that addressing multivessel coronary artery disease using total endoscopic coronary artery bypass offers no obvious clinical benefits and might increase the morbidity and mortality.

Topics: Adult; Aged; Aged, 80 and over; Biomarkers; Blood Transfusion; Cardiovascular Agents; Chi-Square Distribution; Chicago; Coronary Artery Bypass; Coronary Artery Disease; Creatinine; Endoscopy; Female; Hemodynamics; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Logistic Models; Male; Middle Aged; Postoperative Complications; Renal Dialysis; Renal Insufficiency; Respiration, Artificial; Risk Assessment; Risk Factors; Robotics; Stroke; Surgery, Computer-Assisted; Time Factors; Treatment Outcome

Although blunt cerebrovascular injuries (BCVIs) are a well-recognized sequela of trauma in adults, there have been few reports in children. The investigators questioned whether adult screening protocols are appropriate in the pediatric population. The purpose of this study was to describe the incidence, injury patterns, and stroke rates of pediatric patients sustaining BCVIs.. Pediatric patients (aged ≤ 18 years) diagnosed with BCVIs at a regional level I trauma center and a pediatric level I trauma center since 1996 were reviewed.. Forty-five patients sustained BCVIs (60% male; mean age, 13 ± .7 years; mean Injury Severity Score, 23 ± 2). Three patients exsanguinated, and 10 presented with stroke; neurologic changes occurred 17 ± 6 hours after injury (range, 1-72 hours). Screening indications were present in 30%. Thirty-two asymptomatic patients were diagnosed. All but 1 received antithrombotic agents; 1 patient had neurologic deterioration despite heparinization. Comparing asymptomatic patients with those with stroke, there was a significant difference in age (15 vs 11 years).. More than two-thirds of patients presenting with stroke did not have screening indications according to adult protocols. With the availability of noninvasive diagnostic imaging such as computed tomographic angiography, broader screening guidelines for children should be instituted.

Topics: Accidents, Traffic; Adolescent; Angiography; Anticoagulants; Cardiovascular Agents; Carotid Artery Injuries; Cerebrovascular Circulation; Child; Child, Preschool; Colorado; Female; Fibrinolytic Agents; Head Injuries, Closed; Heparin; Humans; Injury Severity Score; Male; Platelet Aggregation Inhibitors; Stroke; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Vertebral Artery; Young Adult

Topics: Aspirin; Cardiovascular Agents; Cause of Death; Female; Humans; Male; Myocardial Infarction; Primary Prevention; Stroke

To evaluate the immediate and long-term outcomes of drug-eluting stent (DES) vs. bare metal stent (BMS) for symptomatic vertebral artery stenosis (VAS).. From 2003 to 2010, 206 consecutive patients (158 men; mean age 66.8 years) underwent DES (sirolimus-eluting or paclitaxel-eluting) or BMS placement for symptomatic extracranial and intracranial stenoses in 219 vertebral arteries. The technical success, clinical success, periprocedural complications, target vessel revascularization (TVR), and overall survival were compared between the DES and BMS groups.. The technical success rate was 98.3% (119/121) for the DES group vs. 100% for the BMS group (p = 0.503). The clinical success rate was 95.5% (107/112) for the DES group vs. 97.9% (92/94) for the BMS group (p = 0.592). No periprocedural death or stroke occurred. The overall periprocedural complication rate was 2.7% (3/112) in the DES group vs. 4.3% (4/94) in BMS group (p = 0.813). The median follow-up was 43 months (range 3-95) for the DES group and 46 months (range 6-89) for BMS. At last follow-up, the TVR rate was 6.3% (7/112) for the DES group vs. 20.2% (19/94) for the BMS group (p = 0.003); 4 (3.6%) patients in the DES group and 8 (8.5%) patients in the BMS group experienced a VBS stroke (p = 0.132). By life-table analysis, the 5-year TVR rate was 4.5% (5/112) for the DES group vs. 19.1% (18/94) for the BMS group (p = 0.001). No difference was detected in the overall survival curves between the groups (p = 0.500).. Both DES and BMS are feasible, safe, and effective for symptomatic VAS. However, DES can significantly decrease the TVR rate in the long term compared with BMS.

Topics: Aged; Cardiovascular Agents; Cerebral Angiography; China; Drug-Eluting Stents; Endovascular Procedures; Female; Humans; Male; Metals; Middle Aged; Multivariate Analysis; Paclitaxel; Proportional Hazards Models; Prosthesis Design; Retrospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stents; Stroke; Survival Analysis; Time Factors; Treatment Outcome; Vertebrobasilar Insufficiency

Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy.. We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (β-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or TIA) score of ≥2 (58.1% versus 67.0%, P<0.001). Treatment with any antithrombotic drug was comparable in the 2 groups (76.8% in rhythm control versus 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control in comparison with rate control therapy (1.74 versus 2.49, per 100 person-years, P<0.001). This association was more marked in patients in the moderate- and high-risk groups for stroke according to the CHADS(2) risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score-matched cohort.. In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Agents; Cohort Studies; Female; Follow-Up Studies; Heart Rate; Humans; Ischemic Attack, Transient; Male; Population Surveillance; Stroke; Treatment Outcome

Topics: Aspirin; Cardiovascular Agents; Cause of Death; Female; Humans; Male; Myocardial Infarction; Primary Prevention; Stroke

Few studies have examined the role of cardiovascular drugs on acute ischaemic stroke prognosis.. To evaluate the relationship between a favourable outcome in patients with acute ischaemic stroke and specific demographic, clinical and laboratory variables and cardiovascular drug pretreatment.. The 1096 patients enrolled in the GIFA study (who had a main discharge diagnosis of ischaemic stroke) represent the final patient sample used in this analysis. Drugs considered in the analysis included angiotensin converting enzyme (ACE)-inhibitors, angiotensin II receptor blockers, statins, calcium channel blockers, anti-platelet drugs, vitamin K antagonists and heparins. The outcomes analyzed included in-hospital mortality, cognitive function evaluated by the Hodkinson Abbreviated Mental Test (HAMT), and functional status evaluated by activities of daily living (ADL). The definition of a good outcome was no in-hospital mortality, a HAMT score of ≥ 6 and no ADL impairment.. Patients with no in-hospital mortality, a HAMT score of >6 and no ADL impairment were more likely to be younger at baseline and have a lower blood glucose level and a systolic blood pressure (SBP) between 120 and 180 mmHg, a higher plasma total cholesterol level, a lower white blood cell count, and a lower Charlson Index (CI) score, a higher rate of pretreatment with ACE-inhibitors, calcium channel blockers and a lower rate of pretreatment with heparin.. Predictors of good outcome, in terms of in-hospital mortality and cognitive and functional performance at discharge, included higher SBP at admission between 120 and 180 mmHg, a SBP plasma total cholesterol levels, a lower CI score, and pretreatment with ACE-inhibitors, calcium channel blockers and anti-platelets.

Topics: Aged; Aged, 80 and over; Brain Ischemia; Cardiovascular Agents; Databases, Factual; Female; Follow-Up Studies; Hospital Mortality; Humans; Italy; Male; Pharmacoepidemiology; Retrospective Studies; Stroke; Treatment Outcome

The magnitude of cardiovascular risk associated with psoriasis has been debated and the prognostic impact of psoriasis following myocardial infarction (MI) is unknown. Therefore, we investigated the risk of mortality and adverse cardiovascular events in patients with psoriasis following first-time MI.. Cohort study of the entire Danish population including all individuals who experienced first-time MI during the period 2002-2006. Multivariable Cox regression models were used to assess the post-MI prognostic impact of psoriasis. Main outcome measures.  All-cause mortality and a composite cardiovascular end-point of recurrent MI, stroke and cardiovascular death.. A total of 462 patients with psoriasis and 48 935 controls (mean age 69.5 and 70.6 years, respectively) were identified with first-time MI during the study period. The mean follow-up was 19.5 months [standard deviation (SD) 16.5] for patients with psoriasis and 22 .0 months (SD 18.7) for those without psoriasis. Incidence rates (IRs) per 1000 patient-years for all-cause mortality were 119.4 [95% confidence interval (CI) 117.2-138.3] and 138.3 (95% CI 114.1-167.7) for patients without and with psoriasis, respectively, and the adjusted hazard ratio (HR) associated with psoriasis was 1.18 (95% CI 0.97-1.43). For the composite end-point, the IRs were 149.7 (95% CI 147.1-152.4) and 185.6 (95% CI 155.8-221.0) for patients without and with psoriasis, respectively, with an HR of 1.26 (95% CI 1.04-1.54) for patients with psoriasis.. This first study of the impact of psoriasis on prognosis after first-time MI indicated a significantly impaired prognosis in patients with psoriasis. Further studies of this novel association are warranted.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Comorbidity; Confounding Factors, Epidemiologic; Denmark; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Prognosis; Prospective Studies; Psoriasis; Recurrence; Registries; Risk Assessment; Risk Factors; Stroke

Information relating the outcome of percutaneous coronary intervention to diabetes mellitus or hypertension is limited. The study objective was to describe the outcome in patients undergoing percutaneous coronary intervention in relation to diabetes and hypertension.. Data were extracted from 5 national registers: the Swedish Coronary Angiography and Angioplasty Register (all percutaneous coronary interventions), the Prescribed Drug Registry (all prescribed pharmaceuticals purchased in Swedish pharmacies), the Swedish Hospital Discharge Register (data on myocardial infarction, revascularization, stroke, and congestive heart failure from in-hospital and specialist health care), and the National Population Register and Cause of Death Register (data on death). We included all "first percutaneous coronary interventions" between January 1, 2006, and December 31, 2008 (n=44,268; followed an average of 1.9 [± 0.9] years).. Mortality was 6.4% and highest in patients with diabetes plus hypertension. Hypertension per se did not increase mortality or the risk for repeat intervention, but carried a 10% increased risk for subsequent myocardial infarction, increasing to a 4-fold increase when combined with diabetes. Stroke occurred in 2%; the importance of hypertension was evident in nondiabetic patients, but even stronger in diabetic patients. Congestive heart failure caused hospital admission in 8%, with a negative influence from hypertension with and without diabetes.. After percutaneous coronary intervention and with modern pharmacotherapy, diabetes had a negative effect on the outcome, especially when combined with hypertension. Hypertension per se was not associated with increased mortality but with an increased risk for myocardial infarction, stroke, and congestive heart failure, probably related to widespread coronary artery disease. Improved diabetes care might improve the prognosis.

Topics: Adult; Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cardiovascular Diseases; Confounding Factors, Epidemiologic; Coronary Disease; Coronary Restenosis; Diabetes Complications; Diabetes Mellitus, Type 2; Female; Follow-Up Studies; Heart Failure; Humans; Hypertension; Hypoglycemic Agents; Male; Middle Aged; Myocardial Infarction; Prognosis; Registries; Retreatment; Stroke; Sweden; Treatment Outcome

Topics: Cardiovascular Agents; Developed Countries; Developing Countries; Disabled Persons; Genetic Predisposition to Disease; Humans; Interdisciplinary Communication; Ischemic Attack, Transient; Life Style; Patient Care Team; Risk Reduction Behavior; Secondary Prevention; Stroke; Stroke Rehabilitation

Topics: Aspirin; Blood Pressure; Cardiovascular Agents; Endarterectomy, Carotid; Fibrinolytic Agents; History, 20th Century; History, 21st Century; Humans; Ischemic Attack, Transient; Predictive Value of Tests; Prognosis; Stroke; United Kingdom

The purpose of this study was to clarify the clinical impact of endovascular treatment (EVT) on acute cerebral large vessel occlusion using a nationwide survey of Japan conducted in 2009.. Patients admitted within 24 h after stroke onset were registered retrospectively. Treatment selection, methods, and clinical results were analyzed.. A total of 1,963 patients (855 women, 1,108 men) treated in 2008 were registered from 68 medical centers in Japan. Mean age on admission was 74.1 ± 12.2 years (range 7-100 years). The first treatment was conservative therapy in 68%, intravenous tissue plasminogen activator (IV-tPA) in 21%, EVT in 9%, and combined IV-tPA + EVT in 2%. EVT mainly comprised angioplasty, intra-arterial thrombolysis and/or the combination of both. Patients treated ≤3 h after onset (1,286 cases) showed better clinical outcomes with combined IV-tPA + EVT than with conservative therapy, and significant differences in outcomes were seen for patients with occlusion of the basilar artery (p < 0.01) or middle cerebral artery (p < 0.01), but not the internal carotid artery. At >3 h after onset (677 patients), no IV-tPA was performed, and EVT was performed in 11%. Among the patients treated by EVT, there were significant differences in clinical outcome between complete recanalization (TIMI grade 3) and partial/no recanalization (TIMI grade 0-2) (p < 0.001; OR 5.98; 95% CI 3.27-10.96) and between any recanalization (TIMI grade 1-3) and no recanalization (TIMI grade 0) (p < 0.001; OR 36.15; 95% CI 4.88-267.53).. This nationwide survey showed the efficacy of EVT with IV-tPA in patients with occlusion of the basilar or middle cerebral artery, but not of the internal carotid artery. The effects of new endovascular devices should be clarified in the near future.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Child; Combined Modality Therapy; Endovascular Procedures; Female; Health Care Surveys; Humans; Infarction, Middle Cerebral Artery; Japan; Male; Middle Aged; Odds Ratio; Patient Selection; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Thrombolytic Therapy; Time Factors; Treatment Outcome; Vertebrobasilar Insufficiency; Young Adult

Topics: Antihypertensive Agents; Cardiovascular Agents; Coronary Disease; Developed Countries; Developing Countries; Female; Humans; Male; Secondary Prevention; Stroke

Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, β blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.. In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35-70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels.. We enrolled 153,996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously [IQR 2·0-10·0]) and 2292 had stroke (4·0 years previously [2·0-8·0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (p(trend)<0·0001 for every drug type). Fewest patients received no drugs in high-income countries (11·2%), compared with 45·1% in upper middle-income countries, 69·3% in lower middle-income countries, and 80·2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28·7% urban vs 21·3% rural, β blockers 23·5%vs 15·6%, ACE inhibitors or ARBs 22·8%vs 15·5%, and statins 19·9%vs 11·6%; all p<0·0001), with greatest variation in poorest countries (p(interaction)<0·0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses).. Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas-systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.. Full funding sources listed at end of paper (see Acknowledgments).

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Data Collection; Developed Countries; Developing Countries; Drug Utilization; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Platelet Aggregation Inhibitors; Rural Population; Secondary Prevention; Stroke; Urban Population

We sought to assess the efficacy and safety of everolimus-eluting stents for unprotected left main disease.. A total of 173 consecutive patients with de novo significant unprotected left main stenosis received an everolimus-eluting stent in four French centres. Among them, 140 (81 %) had involvement of the distal portion of left main, and 129/140 (92%) were treated with provisional side branch T-stenting, with a side branch stenting rate of 20%. Angiographic success was achieved in all cases. At 12 months, the cumulative rate of major adverse cardiac or cerebrovascular events (MACCE) was 26/173 (15%) including death from any cause (N=5, 2.9%), stroke (N=4, 2.3%), Q-wave myocardial infarction (MI) (N=2, 1.2%), non-Q-wave MI (N=6, 3.5%) and any repeat revascularisation (N=16, 9.3%). At one year, the rate of target-lesion revascularisation (TLR) was 5/173 (2.9%), target-vessel revascularisation was 12/173 (7 %) and the rate of definite or probable left main stent thrombosis 1/173 (0.6 %).. Unprotected left main stenting using everolimus-eluting stents and a strategy of provisional side branch T-stenting for distal lesions, is safe and effective in the midterm, with a relatively low rate of events and reintervention at one year.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Drug-Eluting Stents; Everolimus; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Pilot Projects; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Sirolimus; Stroke; Thrombosis; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Coronary Disease; Developed Countries; Developing Countries; Humans; Residence Characteristics; Stroke

Topics: Cardiovascular Agents; Cardiovascular Diseases; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Combinations; Humans; Stroke

We have demonstrated previously that both acute and chronic oral administration of adenosine have novel functions such as anti-hypertensive effects and improved hyperlipidaemia in stroke-prone spontaneously hypertensive rats (SHRSP) fed a normal diet. The purpose of the present study was to investigate the effect of adenosine administration on metabolic syndrome-related parameters in SHRSP fed a high-fat diet. Six-week-old rats were divided into three groups, and were administered either water (control) or adenosine (10 or 100 mg/l) for 8 weeks. During this period, the rats had free access to a high-fat diet based on AIN-93M. The results showed that hypertension, plasma lipid, NO, insulin, glucose and urinary 8-hydroxy-2'-deoxyguanosine levels improved significantly in both adenosine groups. The mRNA expression levels of genes involved in anti-oxidative activity and adenosine receptors were also altered in the adenosine groups. Administration of adenosine also increased plasma adiponectin levels, accompanied by upregulation of mRNA expression level of adiponectin and adiponectin receptor 1 in perirenal fat and adiponectin receptor 2 in the liver. In conclusion, oral administration of adenosine is effective for improving metabolic syndrome-related parameters in SHRSP, and accordingly it may prevent the progression of the metabolic syndrome.

Topics: 8-Hydroxy-2'-Deoxyguanosine; Adenosine; Adiponectin; Adipose Tissue; Animals; Antioxidants; Blood Glucose; Cardiovascular Agents; Deoxyguanosine; Dietary Fats; Enzymes; Gene Expression; Gene Expression Regulation; Hypertension; Insulin; Kidney; Lipids; Liver; Male; Metabolic Syndrome; Nitric Oxide; Rats; Rats, Inbred SHR; Receptors, Adiponectin; RNA, Messenger; Stroke

Atrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD).. The International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or > or =3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used.. Of 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p<0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09-2.0).. AF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Diseases; Chi-Square Distribution; Europe; Female; Humans; Male; Middle Aged; Myocardial Infarction; Outpatients; Peripheral Vascular Diseases; Prevalence; Prognosis; Proportional Hazards Models; Prospective Studies; Registries; Risk Assessment; Risk Factors; Stroke; Time Factors

With the advent of new therapeutic options for acute ischemic stroke, expeditious evaluation of patients with suspected stroke has become imperative. Goals of the initial evaluation are to determine the time of symptom onset, severity of the neurologic deficit, and to exclude intracranial hemorrhage and other mimics of acute ischemic stroke. CT and MRI perfusion studies may demonstrate the presence of an ischemic penumbra and aid in identification of patients who may benefit from thrombolysis. Intravenous recombinant tissue plasminogen activator (IV rtPA) remains the gold standard for acute ischemic stroke treatment, and the therapeutic time window recently has been extended to 4.5 h in certain patients. Catheter-based intra-arterial thrombolysis is being used increasingly as "rescue therapy" after IV rtPA and as primary therapy in select patients who are ineligible for intravenous therapy. Trials investigating the efficacy and safety of intra-arterial therapy are ongoing.

Topics: Brain Ischemia; Cardiovascular Agents; Emergencies; Fibrinolytic Agents; Humans; Stroke; Telemedicine; Tissue Plasminogen Activator

To assess the short-term prognosis of patients with recent symptomatic intracranial atherosclerotic disease in the posterior circulation and evaluate differences in the outcome of patients receiving medical or endovascular treatment.. The records of 50 consecutive patients with symptomatic intracranial atherosclerotic disease in the posterior circulation were reviewed to record the occurrence of transient ischemic attack, stroke, major bleeding, and/or death during the 12-month period following a neurological event. Twenty-five patients received medical treatment alone, 13 initially received medical treatment and subsequently were treated with angioplasty/stenting due to recurrent events (analyzed in both groups), and 12 patients received endovascular treatment initially. The crossover patients were considered as 1 treated patient in each group; thus, there were 38 subjects (33 men; mean age 68+/-9 years) receiving medical therapy compared with 25 patients (21 men; mean age 63+/-13 years) who underwent endovascular procedures.. During the 12-month period, subjects in the medically-treated group had a higher rate of events (37%, 14/38) than patients who received angioplasty/stenting (12%, 3/25; p = 0.042). Notably, there were 7 (18%) TIAs and 6 (16%) strokes in medically-treated patients versus no TIAs (0%, p = 0.035) and only 2 (8%, p = NS) strokes in the endovascular group, both of which occurred within 48 hours of the procedure. There were no deaths and only a single major bleeding event in each group.. Endovascular treatment of patients with symptomatic intracranial disease of the posterior territory appears to be associated with a substantially better outcome.

Topics: Aged; Angioplasty; Argentina; Cardiovascular Agents; Cerebrovascular Circulation; Chi-Square Distribution; Female; Hemorrhage; Humans; Intracranial Arteriosclerosis; Ischemic Attack, Transient; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome

The prospective multicenter German DES.DE registry provides real world data to evaluate the therapeutic principle of two different drug-eluting stents (DES) [Sirolimus- (SES) and Paclitaxel-eluting stent (PES)] in the context of the German Health System.. Differential DES have been effective in randomized trials, but their difference in safety and efficacy in diabetic patients has not been well studied.. Baseline, predefined procedural as well as clinical in-hospital and follow-up events were recorded for all 1,526 diabetic patients. The composite of death, myocardial infarction (MI), and stroke defined as major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) were defined as primary endpoints.. Between October 2005 and October 2006, 1,526 diabetic patients, 34.2% of them being insulin-dependent, were enrolled (SES: n = 612; PES: n = 914) at 98 DES.DE sites. Overall, one third of patients were admitted with acute coronary syndrome (ACS) and 70% had multivessel-disease reflecting a real world scenario. With similar baseline clinical and descriptive morphology of coronary artery disease (CAD) in both DES groups, there were no statistical differences in 1-year follow-up with respect to rates of overall mortality (5.8% vs. 5.4%), TVR (12.0% vs. 11.3%), overall stent thrombosis (5.6% vs. 4.6%) and MACCE (11.4% vs. 10.3%) between both DES.. The data collected in DES.DE revealed no differences in clinical outcomes within 1 year between SES and PES in diabetic patients in a "real-world" setting.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Disease; Diabetes Complications; Drug-Eluting Stents; Female; Germany; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Myocardial Infarction; Odds Ratio; Paclitaxel; Prospective Studies; Registries; Risk Assessment; Risk Factors; Severity of Illness Index; Sirolimus; Stroke; Thrombosis; Time Factors; Treatment Outcome

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Diabetes Complications; Drug-Eluting Stents; Everolimus; Humans; Myocardial Infarction; Paclitaxel; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Sirolimus; Stroke; Thrombosis; Time Factors; Treatment Outcome

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial established that, for patients with stable coronary artery disease (CAD), an initial management strategy of percutaneous coronary intervention plus optimal medical therapy did not reduce the long-term rates of death, myocardial infarction, or other cardiovascular events as compared with optimal medical therapy alone. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial reported that for patients with type 2 diabetes and stable CAD, a strategy of prompt coronary revascularization and intensive medical therapy did not reduce all-cause mortality or the composite of death, myocardial infarction or stroke compared with intensive medical therapy alone; however, in the group of patients appropriate for coronary artery bypass graft surgery (CABG), prompt revascularization with CABG resulted in significantly lower rates of major cardiovascular events, specifically myocardial infarction, than intensive medical therapy alone. The results from these two large multicenter clinical trials have led the medical community to re-evaluate how one should approach and treat patients with CAD and stable ischemic symptoms. In this special issue, experts from several disciplines discuss how the COURAGE and BARI 2D results have affected clinical practice and highlight the key questions that remain unanswered.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Case Management; Clinical Trials as Topic; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Critical Care; Diabetes Mellitus, Type 2; Guideline Adherence; Health Knowledge, Attitudes, Practice; Humans; Mortality; Multicenter Studies as Topic; Myocardial Infarction; Practice Guidelines as Topic; Risk Assessment; Stroke; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Recurrence; Risk Assessment; Risk Factors; Stents; Stroke; Therapeutic Equipoise; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Patient Selection; Risk Assessment; Risk Factors; Stents; Stroke; Treatment Outcome

The extent and implications of age- and sex-related differences in prophylaxis following ischemic stroke are unknown. We examined differences in the use of medical prophylaxis across age and sex groups in stroke patients after hospital discharge in Denmark and estimated the possible impact on age- and sex-related differences in mortality.. A nationwide population-based follow-up study was conducted involving 28,634 patients hospitalized for ischemic stroke in 2003-2006 who survived 30 days after discharge. The proportion of patients who filled prescriptions for cardiovascular drugs within 0-6 and 12-18 months after discharge was determined. Mortality rates were compared across age and sex groups with and without controlling for use of medical prophylaxis.. Increasing age was associated with lower prophylaxis. Adjusted odds ratios for the use of a combination of a platelet inhibitor, an antihypertensive and a statin were 0.45 [95% confidence interval (CI): 0.38-0.54] and 0.52 (95% CI: 0.43-0.62) for men and women >80 years, respectively, compared with men ≤65 years. No systematic sex-related differences were identified. Continued drug use ranged from 66.1 to 91.9% for different drugs 12-18 months after discharge, with the lowest rate of continued use found among patients >80 years. Controlling for use of medical prophylaxis was associated with lower mortality rate ratios for elderly compared with younger patients.. Continuous efforts are warranted to ensure implementation of evidence-based secondary prophylaxis among elderly patients with ischemic stroke.

Topics: Age Factors; Aged; Aged, 80 and over; Brain Ischemia; Cardiovascular Agents; Denmark; Drug Prescriptions; Evidence-Based Medicine; Female; Follow-Up Studies; Hospitalization; Humans; Logistic Models; Male; Middle Aged; Odds Ratio; Patient Discharge; Practice Guidelines as Topic; Proportional Hazards Models; Prospective Studies; Registries; Risk Assessment; Risk Factors; Secondary Prevention; Sex Factors; Stroke; Time Factors; Treatment Outcome

The profile of recurrent ischemic strokes has not been much investigated. The aim of this study was to evaluate how the therapeutic strategies recommended for secondary prevention after an ischemic stroke are implemented in the real world of clinical practice. All patients admitted for a recurrent ischemic stroke or TIA were prospectively registered. The etiology was determined according to the TOAST classification. The risk factors and cardiovascular treatment at the time of the recurrence were recorded. A total of 168 patients were evaluated. Most of the patients (61%) recurred after 1 year. The recurrent stroke was not associated with a particular etiological subtype. The most frequent risk factor was hypertension (79%), followed by hypercholesterolemia (43%), smoking (25%), and diabetes (22%). Most of the patients had more than 1 risk factor (84%). Hypertension was not satisfactorily controlled in 38% of patients, hypercholesterolemia in 42%, and diabetes in 59%. A significant minority of patients (15%) were not taking any antithrombotic agent despite a history of stroke or TIA. Only 34% of the cases with a known atrial fibrillation were on anticoagulant therapy and the International Normalized Ratio was < 2.0 in 71% of them. In conclusion, stroke prevention needs to be improved by better implementation of therapeutic strategies in clinical practice. The patients should also be better informed about target values as well as the importance of physical activity and smoking cessation.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Diabetes Complications; Female; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Secondary Prevention; Smoking; Stroke; Young Adult

Although there is level I evidence supporting the role of carotid endarterectomy (CEA) in patients with asymptomatic disease, opinion remains polarised regarding what constitutes optimal management, especially as carotid artery stenting (CAS) has emerged as a less invasive alternative. Reasons for this lack of consensus amongst surgeons, interventionists, neurologists and stroke physicians include our continued inability to identify 'high risk for stroke' patients in whom to target costly therapies. For example, recent data from the USA suggest that up to $21 billion is being spent each year on ultimately 'unnecessary' interventions. Second, is growing evidence that improvements in what now constitutes modern 'best medical therapy' has significantly reduced the risk of stroke compared to that observed in ACAS and ACST. If true, this will compromise risk:benefit analyses used in national and international guidelines. At a time when evidence suggests that up to 94% of interventions may not benefit the patient, the authors urge that at least one of the randomised trials comparing CEA with CAS in asymptomatic patients includes an adequately powered third limb for BMT. Timely investment now could optimise patient care and resource utilisation for all of us in the future.

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Cost-Benefit Analysis; Endarterectomy, Carotid; Evidence-Based Medicine; Health Care Costs; Humans; Patient Selection; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Research Support as Topic; Risk Assessment; Stents; Stroke; Treatment Outcome; Unnecessary Procedures

Topics: Benzenesulfonates; Cardiovascular Agents; Humans; Quality Control; Reproducibility of Results; Stroke; Treatment Outcome

Atrial fibrillation (AF) has been established as an independent predictor of long-term mortality after acute myocardial infarction. However, this is less well defined across the whole spectrum of acute coronary syndromes (ACSs). The Acute Coronary Syndrome Prospective Audit is a prospective multicenter registry with 12-month outcome data for 3,393 patients (755 with ST-segment elevation myocardial infarction, 1942 with high-risk non-ST-segment elevation ACS [NSTE-ACS], and 696 with intermediate-risk NSTE-ACS). A total of 149 patients (4.4%) had new-onset AF and 387 (11.4%) had previous AF. New-onset AF was more, and previous AF was less frequent in those with ST-segment elevation myocardial infarction than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS (p <0.001). Compared to patients without arrhythmia, patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation (p <0.004). Patients with new-onset AF more often had left main coronary artery disease, resulting in a greater rate of surgical revascularization (p <0.001). Only new-onset AF resulted in adverse in-hospital outcomes (p <0.001). Only patients with previous AF had greater long-term mortality (hazard ratio 1.42, p <0.05). New-onset AF was only associated with a worse long-term composite outcome (hazard ratio 1.66, p = 0.004). However, the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS (odds ratio 3.9, p = 0.02) than for those with high-risk NSTE-ACS (odds ratio 2.0, p = 0.01) or ST-segment elevation myocardial infarction (odds ratio 1.4, p = 0.4). In conclusion, new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up. The prognostic burden of new-onset AF differed with the type of ACS presentation.

Topics: Acute Coronary Syndrome; Acute Kidney Injury; Age Factors; Aged; Atrial Fibrillation; Australia; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Creatine Kinase; Drug Utilization; Electrocardiography; Female; Heart Failure; Heart Rate; Hemorrhage; Hospital Mortality; Humans; Length of Stay; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Recurrence; Registries; Risk Factors; Severity of Illness Index; Stroke

The prospective multicenter German Drug-Eluting Stent (DES.DE) registry is an observational study to analyze and evaluate the therapeutic principle of the differential drug-eluting stents (sirolimus- and paclitaxel-eluting stents) and bare metal stents under real world conditions in the context of the German healthcare system. The baseline clinical and angiographic characteristics and follow-up events for 1 year were recorded for all enrolled patients. In addition, a health economics assessment was performed at 3, 6, 9, and 12 months after initial stent placement. The composite of death, myocardial infarction, and stroke, defined as major adverse cardiac and cerebrovascular events, and target vessel revascularization were used as the primary objectives. From October 2005 to October 2006, 6,384 patients were enrolled (sirolimus-eluting stents, n = 2,137; paclitaxel-eluting stents, n = 2,740; bare metal stents, n = 485) at 98 Deutsches Drug-Eluting Stent Register sites. With similar baseline clinical and descriptive morphology of coronary artery disease between both drug-eluting stent groups, no differences were present at 1 year of follow-up in the rates of overall mortality (3.8% vs 4.1%), target vessel revascularization (10.4% vs 10.4%), overall stent thrombosis (3.6% vs 3.8%), and major adverse cardiac and cerebrovascular events (8.1% vs 8.0%). Compared with the bare metal stent group, patients treated with drug-eluting stents had significantly lower rates of myocardial infarction (3.2% vs 6.0%; p <0.01), stroke (1.2% vs 2.7%; p <0.05), and target vessel revascularization (10.4% vs 14.9%; p <0.01) without any difference in the stent thrombosis rate (3.7% vs 4.3%; p = 0.57) or mortality rate (4.0% vs 5.2%; p = 0.21). In conclusion, the data generated from the German Drug-Eluting Stent registry revealed no differences between patients receiving a paclitaxel-eluting stent and sirolimus-eluting stent in a "real-world" setting with regard to the clinical outcomes at 1 year.

Topics: Aged; Cardiovascular Agents; Coronary Artery Disease; Coronary Occlusion; Coronary Thrombosis; Drug-Eluting Stents; Female; Follow-Up Studies; Germany; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Paclitaxel; Platelet Aggregation Inhibitors; Prospective Studies; Registries; Sirolimus; Stents; Stroke

The recent meta-analysis of NXY-059 in experimental stroke models using individual animal data found the drug to be an effective neuroprotective agent. However, the failure of translation of both this compound and many others from preclinical studies to the clinic indicates that new approaches must be used in drug discovery so that animal models become more reflective of the clinical situation, and studies using animal models of stroke mimic the design of studies performed in humans, as far as possible. In this review, we suggest that a fundamental paradigm shift is needed away from performing preclinical studies in individual laboratories to performing them in an organised group of independent laboratories. Studies should be run by a steering committee and should be supported by a coordinating centre, external data monitoring committee and outcome adjudication committee. This structure will mimic the practice of multicentre clinical trials. By doing so, future studies will minimise potential sources of bias including randomisation, concealment of allocation, blinding of surgery and outcome assessment and ensure publication of all data. It is likely that individual studies will involve increased heterogeneity and therefore will need to be larger. However, regular independent monitoring of data will allow development of interventions to be ceased immediately if neutral or negative data are obtained. The additional costs involved should be seen as reasonable when compared with the resources that would have been expended in running a clinical trial that subsequently proved negative.

Topics: Age Factors; Animals; Benzenesulfonates; Cardiovascular Agents; Data Interpretation, Statistical; Disease Models, Animal; Drug Discovery; Drug Evaluation, Preclinical; Humans; Multicenter Studies as Topic; Placebos; Random Allocation; Randomized Controlled Trials as Topic; Research Design; Sample Size; Sex Factors; Stroke

Striatal cholinergic interneurons are relatively resistant to ischemic insults. These neurons express hyperpolarization-activated cation current (I(h)) that profoundly regulates neuronal excitability. Changes in neuronal excitability early after ischemia may be crucial for determining neuronal injury. Here we report that I(h) in cholinergic interneurons was decreased 3 h after transient forebrain ischemia, which was accompanied by a negative shift of the voltage dependence of activation. The inhibition of I(h) might be due to the tonic activation of adenosine A1 receptors, as blockade of A1 receptors significantly increased I(h) in postischemic neurons, but had no effect on control neurons. Consistent with the inhibition of I(h), postischemic neurons showed a reduction in both spontaneous firing and hyperpolarization-induced rebound depolarization. These findings indicate that I(h) may play excitatory roles in striatal cholinergic interneurons. Postischemic inhibition of I(h) might be a novel mechanism by which adenosine confers neuronal resistance to cerebral ischemia.

Topics: Animals; Calcium; Cardiovascular Agents; Cholinergic Fibers; Corpus Striatum; Cyclic AMP; Interneurons; Ischemic Attack, Transient; Male; Membrane Potentials; Organ Culture Techniques; Patch-Clamp Techniques; Pyrimidines; Rats; Rats, Wistar; Receptor, Adenosine A1; Stroke

There have now been numerous phase III trials of neuroprotection that have failed to live up to the expectations created by preclinical testing in animal models, the most recent of which was the second pivotal trial of the spin trap agent NXY-059. We have reached a stage at which research in this area should stop altogether or radical new approaches adopted. The purpose of this article is to review how we reached this stage and make recommendations for a new approach to neuroprotection research.. The background to neuroprotection research is reviewed and its problems are highlighted based on the research of others and of our own research group. From this, a series of questions are posed that require answers if the field is to progress. A road map for future research is then proposed.. The road map involves the following steps for putative neuroprotectants: (1) better proof of efficacy in animal models; (2) in vivo evidence of efficacy in human tissue using cell cultures or brain slices; (3) in vivo studies of their distribution in the normal and ischemic human brain, particularly focusing on the ischemic penumbra; (4) demonstration of efficacy in novel human models of cerebral ischemia; and (5) phase II and III clinical trails with penumbral selection using imaging techniques.. The accumulated evidence suggests that neuroprotection failure in clinical trial is due to identifiable preclinical and clinical factors. Neuroprotection research should be pursued but with a very different and more rigorous approach.

Topics: Animals; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Clinical Trials, Phase II as Topic; Clinical Trials, Phase III as Topic; Disease Models, Animal; Free Radical Scavengers; Humans; Neuroprotective Agents; Stroke

Much effort has been made to study first-ever stroke patients. However, recurrent stroke has not been investigated as extensively. It is unclear which risk factors dominate, and whether adequate secondary prevention has been provided to patients who suffer from recurrent stroke. Also, the different types of recurrent stroke need further evaluation.. The study included patients with recurrent stroke admitted to twenty-three Swedish stroke centers. The type of previous and recurrent stroke was determined, as well as evaluation (when applicable) of recurrent ischemic stroke according to the TOAST classification. Presence of vascular risk factors was registered and compared to the type of stroke. Also assessed was ongoing secondary prevention treatment at recurrent stroke onset.. A total of 889 patients with recurrent stroke (mean age 77) were included in the study. Of these, 805 (91%) had ischemic stroke, 78 (9%) had intracerebral hemorrhage and 6 (<1%) stroke of unknown origin. The most frequent vascular risk factors were hypertension (75%) and hyperlipidemia (56%). Among the 889 patients, 29% had atrial fibrillation. Of the patients in the ischemic group with cardiac embolism, only 21% were on anticoagulation treatment. The majority of the patients (75%) had their most recent previous stroke >12 months before admission.. Few patients had a recurrent stroke shortly after the previous stroke in this study. This indicates that it is meaningful to prevent a second event with an adequate long-term treatment strategy for secondary prevention after first-ever stroke. There also seems to be a clear potential for improving secondary prevention after stroke.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Cerebral Hemorrhage; Diabetes Complications; Embolism; Female; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Registries; Risk Assessment; Risk Factors; Secondary Prevention; Smoking; Stroke; Sweden; Time Factors; Treatment Outcome

Topics: Animals; Brain Ischemia; Cardiovascular Agents; Humans; Interleukin 1 Receptor Antagonist Protein; Stroke

Cardiovascular disease is an important cause of morbidity and death in kidney transplant recipients. This study examines the Framingham risk score's ability to predict cardiac and stroke events. Because cyclosporine and tacrolimus have different cardiovascular risk profiles, these agents were also examined.. A prospective cohort evaluation of 540 patients were followed for a median of 4.7 yr in an outpatient kidney transplant clinic. Baseline Framingham risk scores were calculated and all cardiovascular outcomes were collected.. Rates per 100 patient-years were 1.79 for cardiac and 0.78 for stroke events. The ratio of observed-to-predicted cardiac events was 1.64-fold higher [95% confidence interval (CI) 1.19 to 2.94] for the cohort, 2.74-fold higher (95% CI 1.70 to 4.24) in patients age 45 to 60 with prior cardiac disease or diabetes mellitus, but not higher in other age subgroups. Stroke was not increased above predicted. Risk scores for cardiac (c = 0.65, P = 0.003) and stroke (c = 0.71, P = 0.004) events were modest predictors. 10-yr event scores for cardiac (9.3 versus 13.5%, P < 0.001) and stroke (7.1 versus 10.0%, P = 0.002) were lower for tacrolimus compared with cyclosporine-treated patients. However observed cardiac events were higher in tacrolimus recipients (2.50, 95% CI 1.09 to 5.90) in an adjusted Cox model.. Although risk scores are only modest predictors, patients with the highest event rates are easily identified. Treating high-risk patients with cardioprotective medications should remain a priority.

Topics: Adult; Age Factors; Aged; Ambulatory Care Facilities; Cardiovascular Agents; Cyclosporine; Diabetes Complications; Disease-Free Survival; Female; Health Status Indicators; Heart Diseases; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Middle Aged; Predictive Value of Tests; Proportional Hazards Models; Prospective Studies; Risk Assessment; Risk Factors; Stroke; Tacrolimus; Time Factors

Previous studies reveal major differences in the estimated cardiovascular risk in diabetes mellitus, including uncertainty about the risk in young patients. Therefore, large studies of well-defined populations are needed.. All residents in Denmark > or = 30 years of age were followed up for 5 years (1997 to 2002) by individual-level linkage of nationwide registers. Diabetes patients receiving glucose-lowering medications and nondiabetics with and without a prior myocardial infarction were compared. At baseline, 71 801 (2.2%) had diabetes mellitus and 79 575 (2.4%) had a prior myocardial infarction. Regardless of age, age-adjusted Cox proportional-hazard ratios for cardiovascular death were 2.42 (95% confidence interval [CI], 2.35 to 2.49) in men with diabetes mellitus without a prior myocardial infarction and 2.44 (95% CI, 2.39 to 2.49) in nondiabetic men with a prior myocardial infarction (P=0.60), with nondiabetics without a prior myocardial infarction as the reference. Results for women were 2.45 (95% CI, 2.38 to 2.51) and 2.62 (95% CI, 2.55 to 2.69) (P=0.001), respectively. For the composite of myocardial infarction, stroke, and cardiovascular death, the hazard ratios in men with diabetes only were 2.32 (95% CI, 2.27 to 2.38) and 2.48 (95% CI, 2.43 to 2.54) in those with a prior myocardial infarction only (P=0.001). Results for women were 2.48 (95% CI, 2.43 to 2.54) and 2.71 (95% CI, 2.65 to 2.78) (P=0.001), respectively. Risks were similar for both diabetes types. Analyses with adjustments for comorbidity, socioeconomic status, and prophylactic medical treatment showed similar results, and propensity score-based matched-pair analyses supported these findings.. Patients requiring glucose-lowering therapy who were > or = 30 years of age exhibited a cardiovascular risk comparable to nondiabetics with a prior myocardial infarction, regardless of sex and diabetes type. Therefore, requirement for glucose-lowering therapy should prompt intensive prophylactic treatment for cardiovascular diseases.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Denmark; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Female; Forecasting; Humans; Hypoglycemic Agents; Insulin; Male; Middle Aged; Myocardial Infarction; Proportional Hazards Models; Recurrence; Registries; Risk; Stroke; Survival Analysis

Patients with diabetes mellitus (DM) and coronary artery disease (CAD) have a poor prognosis. Underutilization and reduced efficacy of evidence-based medications (EBM) or revascularization are among suggested explanations. This report compares the impact of EBM and revascularization on mortality and cardiovascular events (CVE=mortality, myocardial infarction or stroke) in CAD patients with and without DM.. Between February 2003 and January 2004 the Euro Heart Survey on Diabetes and the Heart recruited patients with CAD at 110 centers in 25 European countries. The patients were followed with respect to one-year CVE.. The study population included a total of 3488 patients: 2063 (59%) in the non-DM and 1425 (41%) in the DM group. EBM was defined as the combined use of renin-angiotensin-aldosterone system inhibitors, beta blockers, antiplatelets and statins while revascularization comprised thrombolysis, percutaneous coronary intervention or coronary artery bypass grafting.. Of the eligible patients, 44% with DM and 43% of those without DM received EBM, while 34 and 40% were revascularized. In patients with DM both EBM (0.37, 95% confidence interval (CI), 0.20-0.67, P=0.001) and revascularization (0.72, 95% CI, 0.39-1.32, P=0.275) had an independent protective effect as regards one-year mortality and as regards CVE (0.61, 95% CI, 0.40-0.91, P=0.015 and 0.61, 95% CI, 0.39-0.95, P=0.025, respectively) in patients with DM compared with the impact of these two approaches in those without DM.. The systematic use of EBM and revascularization has a highly rewarding, favorable impact on one-year prognosis of DM patients with CAD.

Topics: Adrenergic beta-Antagonists; Aged; Angioplasty, Balloon, Coronary; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus; Europe; Evidence-Based Medicine; Female; Follow-Up Studies; Health Care Surveys; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Platelet Aggregation Inhibitors; Stroke; Thrombolytic Therapy; Time Factors; Treatment Outcome

As a consequence of our "western" diet and lifestyle, the risk for cardiovascular diseases is increased in the western world. It can be decreased by influencing the LDL-cholesterol values, the blood pressure and the platelet aggregation. It is, however, not proven that lowering of serum homocysteine levels reduces the risk forcardiovascular diseases. Wald and Law suggest in their epidemiological study a polypill, which has as its ingredients a statin, an anti-hypertonic drug, folic acid, and aspirine. Overall, the risk reduction by a polypill is overestimated, since a threshold is currently not existing, in all drugs side effects and interactions are possible, pharmaceuticals are only labelled for specific indications, and with missing efficacy there could be a negative risk-benefit-relation. Indeed, a combined therapy with different drugs is in place in patients with higher risk and for secondary prevention, which is already risk-adjusted. The use of effective drugs, however, in patients without evidence of a positive risk-benefit-relation and without medical control cannot be justified. Therefore, the application of the polypill for subjects beyond 55 years of age is an illusion; by contrast, treatment of patients with a high risk for atherosclerotic diseases is already reality.

Topics: Aged; Cardiovascular Agents; Drug Combinations; Humans; Middle Aged; Myocardial Infarction; Randomized Controlled Trials as Topic; Risk Assessment; Stroke; Survival Rate

Topics: Cardiovascular Agents; Diagnostic Tests, Routine; Disease Management; Drug Utilization; Europe, Eastern; Health Services Accessibility; Health Services Needs and Demand; Hospital Bed Capacity; Hospital Units; Hospitals, Special; Humans; Incidence; Registries; Stroke; Stroke Rehabilitation; Thrombolytic Therapy

The SAINT I trial demonstrated that the neuroprotective agent NXY-059 improves the distribution of acute stroke patient outcomes on the modified Rankin Scale (mRS) of global disability. Standard dichotomized number-needed-to-treat (NNT) analyses for the magnitude of treatment benefit range widely, from 22.7 to infinity, and each capture only a portion of the observed beneficial shift in outcomes. Derivation of an NNT value reflecting the treatment's benefit over the entire range of the mRS is required to describe the clinical import of the trial results.. The minimum and maximum possible NNTs for benefit over the range of mRS global disability outcomes were calculated by completing a joint distribution outcome table for a model population of 1000 patients, shifting responders by the greatest and smallest possible increments, respectively. The biologically most plausible NNT within this range was derived by having 10 neurologist and emergency-physician acute stroke-care experts independently specify the joint distribution of outcomes in model samples of 1000 patients assigned to placebo and active therapy.. The minimum possible NNT for benefit incorporating all mRS state transitions is 7.9 and the maximum is 16.7. The biologically most plausible NNT for 1 additional patient to have a better outcome by 1 or more grades on the mRS outcomes is 9.8 (95% CI, 8.7 to 10.9).. Considering improvements in global disability over the entire outcome range, the SAINT I trial results indicate that for every 100 patients treated, approximately 10 will benefit and none be harmed as a result of treatment.

Topics: Benzenesulfonates; Cardiovascular Agents; Clinical Trials as Topic; Confidence Intervals; Humans; Neuroprotective Agents; Sample Size; Stroke

Topics: Acute Disease; Animals; Benzenesulfonates; Cardiovascular Agents; Drug Evaluation, Preclinical; Humans; Reproducibility of Results; Research Design; Stroke

Topics: 3',5'-Cyclic-AMP Phosphodiesterases; 5-Lipoxygenase-Activating Proteins; Benzenesulfonates; Cardiovascular Agents; Carrier Proteins; Clinical Trials as Topic; Cyclic Nucleotide Phosphodiesterases, Type 4; Humans; Membrane Proteins; Nitrogen Oxides; Stroke

Topics: Acute Disease; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Data Interpretation, Statistical; Hemorrhage; Humans; Nitrogen Oxides; Stroke

Topics: Acute Disease; Benzenesulfonates; Brain Ischemia; Cardiovascular Agents; Data Interpretation, Statistical; Humans; Nitrogen Oxides; Stroke

Limited data are available on management of outpatients with stroke or transient ischemic attack (TIA) and on clinicians' reasons for withholding procedures recommended by guidelines. We assessed to what extent guidelines are appropriately applied after ischemic stroke or TIA, in admitted patients as well as outpatients.. A survey was conducted in 11 centers in the Netherlands, which prospectively enrolled 579 admitted patients and 393 outpatients. Data were collected by trained research assistants. Duplicate assessment in 10% of patients showed good agreement with neurologists (median kappa=0.86). Treating neurologists were asked to provide arguments for withholding recommended procedures in eligible patients.. Recommended acute procedures were provided in the majority of admitted patients, but less often in outpatients: brain imaging (98% and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests (97% and 86%), aspirin within 48 hours (90% and 68% of eligible patients). Secondary preventive measures were not always taken in both eligible inpatients and eligible outpatients: carotid endarterectomy (provided in 31% and 30% of patients), antiplatelet agents (93% and 90%), oral anticoagulants (60% and 48%), antihypertensive agents (57% and 44%), and cholesterol-lowering therapy (71% and 52%). Reasons for withholding recommended procedures were plausible for almost all admitted patients, but were unclear in the majority of outpatients.. Compared with other national stroke surveys, we found high-quality acute care in admitted ischemic stroke patients, whereas secondary prevention was comparably poor. Although the majority of our centers have rapid-access TIA clinics, there is still substantial potential to improve quality of stroke care in outpatients.

Topics: Aged; Ambulatory Care; Cardiovascular Agents; Diagnostic Imaging; Diagnostic Tests, Routine; Drug Utilization; Early Diagnosis; Endarterectomy, Carotid; Female; Guideline Adherence; Health Surveys; Hospital Units; Hospitals, University; Humans; Inpatients; Ischemic Attack, Transient; Male; Middle Aged; Netherlands; Outpatient Clinics, Hospital; Outpatients; Prospective Studies; Quality Assurance, Health Care; Quality of Health Care; Stroke; Thrombolytic Therapy; Time Factors; Withholding Treatment

The 31st International Stroke Conference, held February 16-18, 2006, in Kissimmee, Florida, U.S.A., highlighted more than 550 presentations emphasizing basic and translational sciences and explored how these sciences evolve to unlock our understanding of stroke pathophysiology with the aim of developing more effective prevention diagnosis and treatment tools. This year's conference reached record attendance, with more than 4,000 participants. In this report we will focus on new diagnostic and therapeutic stroke targets addressed in the meeting, together with the trends in neurovascular research presented at the oral and poster sessions of this two-and-a-half day congress.

Topics: Animals; Cardiovascular Agents; Clinical Trials as Topic; Humans; Molecular Structure; Stroke

Topics: Aged; Aspirin; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Clopidogrel; Endarterectomy, Carotid; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Platelet Aggregation Inhibitors; Stents; Stroke; Ticlopidine

Topics: Animals; Benzenesulfonates; Cardiovascular Agents; Clinical Trials, Phase III as Topic; Drug Industry; Humans; Stroke

The rationale for the use of a biventricular assist device (BiVAD) for morbid congestive heart failure (MCHF) has been questioned because of historically unacceptable rates of postimplant and post-transplant mortality as well as perceived barriers to their outpatient management.. All patients who received a Thoratec BiVAD from January 1990 to December 2003 at the University of Pittsburgh were studied retrospectively. There were a total of 73 patients (32% ischemic, 21% idiopathic, and 47% other) who had a BiVAD implanted. Before implantation, 100% were on > or =1 inotropic agent, and 77% had an intra-aortic balloon pump. Overall survival was 69%; 42 patients (84%) received cardiac transplantation, 5 patients (10%) were weaned, and 3 (6%) remained supported on BiVAD. If the 14 patients with postcardiotomy failure and acute myocardial infarction with shock are excluded, the overall survival improves to 75%. Five-year actuarial survival after heart transplantation was 58%. Of the 29 patients implanted before 2000, the 4-month actuarial freedom from driveline infections, bloodstream infections, and neurological events was 10%, 54%, and 48%, respectively, whereas the rates of these events for the 44 patients implanted after 2000 improved to 70%, 79%, and 80%, respectively. Since 2000, 21 (48%) patients were discharged from the hospital, of whom 38% went to an outpatient residence, 33% to a skilled nursing facility, and 29% to home. Once discharged, > or =1 readmission occurred in 45% and > or =2 readmissions in 48%.. BiVAD support for MCHF has an acceptable overall mortality and survival to transplantation. Morbidity has been significantly reduced in the past 4 years, and management as an outpatient is achievable.

Topics: Adult; Ambulatory Care; Cardiovascular Agents; Combined Modality Therapy; Device Removal; Equipment Design; Female; Heart Failure; Heart Transplantation; Heart-Assist Devices; Hospitalization; Humans; Infections; Institutionalization; Intra-Aortic Balloon Pumping; Life Tables; Male; Middle Aged; Postoperative Complications; Prospective Studies; Retrospective Studies; Risk Factors; Skilled Nursing Facilities; Stroke; Survival Analysis; Treatment Outcome

Topics: Alcohol Drinking; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Surgical Procedures; Carotid Stenosis; Clinical Trials as Topic; Combined Modality Therapy; Diabetes Complications; Diabetes Mellitus; Epidemiologic Studies; Evidence-Based Medicine; Hormone Replacement Therapy; Humans; Hypercholesterolemia; Hypertension; Life Style; Smoking; Stroke

Topics: Cardiovascular Agents; Comorbidity; Female; Health Knowledge, Attitudes, Practice; Health Priorities; Heart Diseases; Humans; Life Style; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Stroke

Atherothrombosis is a systemic disease affecting coronary, cerebral, and lower limb arteries, and requiring secondary prevention measures.. Data from three observational studies carried out in 1999-2000 (ECLAT1, APRES, PRISMA) were pooled to describe the prevalence of cardiovascular risk factors and the patterns of drug use in atherothrombotic patients.. General practitioners and cardiologists engaged in a private practice and evenly distributed in France recruited consecutive patients who had a history of at least one atherothrombotic event: myocardial infarction (MI), ischaemic stroke, and/or peripheral arterial disease (PAD).. The sample was composed of 14 544 patients (men: 75.0%, age 75 or older: 31.0%). At least one of the four major risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) was present in 94.3% of the sample. Prevalence of drug use was: 78.8% (antiplatelet agents), 48.5% (statins), 36.7% (beta-blockers), and 33.4% [angiotensin-converting enzyme (ACE) inhibitors]. After adjustment for confounders, statins were taken in a significantly larger extent in patients with a history of isolated MI than in those with a previous ischaemic stroke or PAD, or in patients who suffered from both MI and ischaemic stroke. Isolated MI (as compared with ischaemic stroke and PAD) was significantly and independently associated with a higher probability to take antiplatelet agents, beta-blockers or ACE inhibitors.. At least one conventional risk factor was observed in almost all atherothrombotic patients. Use of preventive drugs was lower in patients with a history of ischaemic stroke or PAD, and should increase, accordingly to the results of recent randomized controlled trials.

Topics: Adult; Aged; Brain Ischemia; Cardiovascular Agents; Diabetes Mellitus, Type 2; Female; France; Humans; Hypercholesterolemia; Hypertension; Life Style; Male; Middle Aged; Myocardial Infarction; Peripheral Vascular Diseases; Prevalence; Risk Factors; Smoking; Stroke

The information on the existence of sex differences in management of stroke patients is scarce. We evaluated whether sex differences may influence clinical presentation, resource use, and outcome of stroke in a European multicenter study.. In a European Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin Scale).. Overall, 2239 patients were males and 2260 females. Compared with males, female patients were significantly older (mean age 74.5+/-12.5 versus 69.2+/-12.1 years), more frequently institutionalized before stroke, and with a worse prestroke Rankin score (all values P<0.001). History of hypertension (P=0.007) and atrial fibrillation (P<0.001) were significantly more frequent in female stroke patients, as were coma (P<0.001), paralysis (P<0.001), aphasia (P=0.001), swallowing problems (P=0.005), and urinary incontinence (P<0.001) in the acute phase. Brain imaging, Doppler examination, echocardiogram, and angiography were significantly less frequently performed in female than male patients (all values P<0.001). The frequency of carotid surgery was also significantly lower in female patients (P<0.001). At the 3-month follow-up, after controlling for all baseline and clinical variables, female sex was a significant predictor of disability (odds ratio [OR], 1.41; 95% CI 1.10 to 1.81) and handicap (OR, 1.46; 95% CI 1.14 to 1.86). No significant gender effect was observed on 3-month survival.. Sex-specific differences existed in a large European study of hospital admissions for acute stroke. Both medical and sociodemographic factors may significantly influence stroke outcome. Knowledge of these determinants may positively impact quality of care.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Alcohol Drinking; Atrial Fibrillation; Brain Damage, Chronic; Brain Ischemia; Cardiovascular Agents; Case Management; Comorbidity; Diabetes Mellitus; Diagnostic Imaging; Europe; Female; Follow-Up Studies; Glasgow Coma Scale; Humans; Hypertension; Hypoglycemic Agents; Institutionalization; Length of Stay; Male; Middle Aged; Myocardial Infarction; Patient Discharge; Prognosis; Registries; Risk Factors; Severity of Illness Index; Sex Factors; Smoking; Stroke; Stroke Rehabilitation; Subarachnoid Hemorrhage; Survival Analysis; Treatment Outcome

Topics: Anticoagulants; Atrial Fibrillation; Cardiovascular Agents; Humans; Pacemaker, Artificial; Risk Factors; Sick Sinus Syndrome; Stroke

To evaluate whether the elevated blood pressure induced by chronic treatment with N(omega)-nitro-L-arginine methyl ester (L-NAME) contributes to an impairment of endothelium-dependent relaxation (EDR), the effects of chronic treatment of Wistar rats with L-NAME on systolic blood pressure, pulmonary arterial blood pressure and EDR of the pulmonary arteries were studied and compared with those of stroke-prone spontaneously hypertensive rats (SHRSP). While the systolic blood pressure (SBP) of Wistar rats was increased above that of controls by chronic treatment with L-NAME, it was still significantly lower than that of SHRSP. Chronic treatment with L-NAME did not affect pulmonary arterial blood pressure. On the other hand, the pulmonary arterial blood pressure of SHRSP was slightly but significantly higher than that of the control normotensive Wistar Kyoto rats (WKY). EDR in response to acetylcholine in the pulmonary artery of L-NAME-treated rats was significantly smaller than that in control Wistar rats. The EDR markedly increased in the presence of L-arginine and completely disappeared in the presence of N(omega)-nitro-L-arginine. Indomethacin hardly affected EDR. In preparations from SHRSP, the EDR was not different from that in those from WKY. Relaxation induced by sodium nitroprusside was identical in all preparations. Elevation of SBP and the impairment of EDR observed in L-NAME-treated rats recovered two weeks following cessation of treatment. These results suggest that the impaired EDR in the pulmonary artery of L-NAME-treated rats is not due to an L-NAME-induced increase in blood pressure but due to the inhibition of nitric oxide synthase by the drug remaining in the endothelium.

Topics: Animals; Arginine; Blood Pressure; Body Weight; Cardiovascular Agents; Endothelium, Vascular; Enzyme Inhibitors; Genetic Predisposition to Disease; Hypertension; Indomethacin; Male; NG-Nitroarginine Methyl Ester; Nitric Oxide Donors; Nitroarginine; Nitroprusside; Pulmonary Artery; Rats; Rats, Inbred SHR; Rats, Inbred WKY; Rats, Wistar; Stroke; Vasodilation

To determine the prevalence of stroke risk factors in a general practice population and to identify pharmacotherapies currently used in management of stroke risk factors.. Multicentre, observational study by 321 randomly selected general practitioners who each collected data on 50 consecutive patients attending their surgery.. 16 148 patients aged 30 years or older attending general practices across Australia during 2000.. Prevalence of hypertension, current smoking, diabetes, hypercholesterolaemia, atrial fibrillation, recent history of stroke or TIA; extent of pharmacotherapy use in risk-factor management.. 70% of patients had one or more risk factors and 34% had two or more. Hypertension was the risk factor with greatest prevalence (44%), followed by hypercholesterolaemia (43%) and current smoking (17%). The prevalence of risk factors generally increased with age, except for current smoking, where a decrease with age was seen. The most common pharmacotherapies were cardiovascular agents, followed by antiplatelet agents. Two-thirds of patients with hypertension were taking cardiovascular drugs, most commonly angiotensin-converting enzyme inhibitors.. Stroke risk factors are highly prevalent in general practice patients and GPs are ideally placed for opportunistic case-finding. There is considerable scope for improving management of stroke risk factors. The Avoid Stroke as Soon as Possible (ASAP) general practice stroke audit provides a baseline against which progress in risk-factor management can be measured.

Topics: Adult; Aged; Aged, 80 and over; Australia; Cardiovascular Agents; Diabetes Mellitus; Family Practice; Female; Hematologic Agents; Humans; Hypercholesterolemia; Hypertension; Hypoglycemic Agents; Male; Medical Audit; Middle Aged; Multicenter Studies as Topic; Prevalence; Risk Factors; Stroke

The aim of this study was to evaluate coagulative and hemorheologic assessment in patients with dilatative cardiomyopathy with or without spontaneous echo contrast (SEC). We studied 45 patients, 35 males and 10 females (mean age 72.1 +/- 9.2). We measured whole blood viscosity, plasmatic fibrinogen, prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimer and red cell morphology with Zipursky-Forconi method. Transthoracic and transesophageal echocardiography was performed in all patients to evaluate the presence of SEC in left atrium. We divided all the patients into two groups: the 1st group of 20 patients with SEC and Atrial Fibrillation (AF) in 80% of cases, and the 2nd group of 25 patients without SEC and AF in 31%. Our results show that in patients with SEC there is a statistically significant increase of whole blood viscosity and plasma fibrinogen in comparison with patients without SEC. Red cell morphology in all patients demonstrates a reversed EMI. D-Dimer, was out of the normal range in about 1/3 of the patients in both groups. An analysis of our results points out that in patients with SEC and AF, with a major risk factor for cardioembolic stroke, we have alterations of hemorheologic assessment with an increase of whole blood viscosity and fibrinogen that seems to be caused by an increase of red cells aggregability favoured by fibrinogen. Our conclusions are that SEC in patients with dilatative cardiomyopathy and AF is an important in vivo indicator of hemorheologic imbalance and an important marker for cardioembolic risk stroke evaluation.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Blood Viscosity; Cardiomyopathy, Dilated; Cardiovascular Agents; Echocardiography, Transesophageal; Erythrocytes; Female; Fibrin Fibrinogen Degradation Products; Fibrinogen; Heart Atria; Hematocrit; Hemorheology; Humans; Male; Middle Aged; Partial Thromboplastin Time; Prothrombin Time; Risk Factors; Stroke; Stroke Volume