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Volume 12 Issue 8

ContentsStroke Prevention in Atrial Fibrillation: Looking Forward4ReStore Soft Exo-Suit for gait rehabilitation: Medtech innovation briefing [MIB239]5COVID-19 associated arterial ischaemic stroke and multisystem inflammatory syndrome in children: a case report6Age in relation to comorbidity and outcome in patients with high-risk TIA or minor ischemic stroke: A Swedish national observational study7Safety and Outcome of Decompressive Hemicraniectomy After Recombinant Tissue Plasminogen Activator Thrombolysis for Acute Ischemic Stroke: A Systematic Review8Venous and arterial thromboembolic events with immune checkpoint inhibitors: A systematic review9Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.11Multivariable risk scores for predicting short term outcomes for emergency department patients with unexplained syncope: a systematic review12Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.13Interventions for improving oral health in people after stroke14Fluoxetine for stroke recovery improvement – the doubleblind, randomised placebo-controlled FOCUS-Poland trial15Five-Year Risk of Acute Myocardial Infarction After Acute Ischemic Stroke in Korea.17Urate, Blood Pressure, and Cardiovascular Disease: Evidence From Mendelian Randomization and Meta-Analysis of Clinical Trials18Heterogeneity of diabetes as a risk factor for major adverse cardiovascular events in anticoagulated patients with atrial fibrillation: an analysis of the ARISTOTLE trial19Iron chelators for acute stroke20Blood pressure targets in adults with hypertension21Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride22Does coronavirus cause stroke? A look at the current research23Stroke risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases24Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis25Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis26Antiphospholipid Antibody and Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis27Quality of Stroke Patient Information Applied in Randomized Controlled Trials-Literature Review28A systematic review of social service and community resource interventions following stroke29The Association of Overt and Subclinical Hyperthyroidism with the Risk of Cardiovascular Events and Cardiovascular Mortality: Meta-Analysis and Systematic Review of Cohort Studies30Scientists test new “algorithm" to help prevent heart attacks31Symptoms of depression linked to increased risk of heart disease and stroke32People with heart and circulatory conditions at higher risk of dying from flu33Trial resumes to prevent dementia after a stroke34Scientists discover why the heart slows down at night35The BHF's research highlights of 202036THROMBOLYSIS IN UNKNOWN STROKE ONSET: BROADENING THE HORIZON WITH ADVANCED BRAIN IMAGING37

Stroke Prevention in Atrial Fibrillation: Looking Forward

Source: Circulation

Follow this link for full text

Date of publication: 14 December 2020

Publication type: Review Article

In a nutshell:

Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.

Length of publication: Journal article

Some important notes: Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

ReStore Soft Exo-Suit for gait rehabilitation: Medtech innovation briefing [MIB239]

Source: NICE Evidence


Date of publication: 1st December 2020

Publication type: Guidelines

In a nutshell:

NICE has developed a medtech innovation briefing (MIB) on ReStore Soft Exo-Suit for gait rehabilitation.



COVID-19 associated arterial ischaemic stroke and multisystem inflammatory syndrome in children: a case report

Source: Lancet Child & Adolescent Health


Date of publication: 27th October 2020

Publication type: Case Report

In a nutshell:

MIS-C is rare; of 662 cases reported so far,19 only the case in this report has presented with acute ischaemic stroke. Considering the emerging evidence of this disease, clinicians should include SARS-CoV-2 in their differential diagnosis for children presenting with new neurological symptoms, positive inflammatory markers, and suggestive imaging findings while exploring other possible causes. Aggressive therapy to halt the cytokine storm and relevant supportive care while considering differential diagnoses is crucial for reaching positive outcomes in children. Further studies are required to understand the pathogenesis of ischaemic stroke and assess the neurological and cognitive outcomes in children with COVID-19.

Length of publication: Case report


Age in relation to comorbidity and outcome in patients with high-risk TIA or minor ischemic stroke: A Swedish national observational study

Source: European Stroke Journal


Date of publication: 13th December 2020

Publication type: Review

Abstract

Introduction

Recent trials report positive results for preventing vascular events with dual antiplatelet therapy (DAPT) in patients with high-risk TIA or minor ischemic stroke. We aimed to investigate this population regarding influence of age on vascular risk factors, hospital stay and mortality.

Patients and methods

Data on patients aged 40–100 years with TIA or ischemic stroke in the Swedish Stroke Register during 2012–13 were linked with national registers. To identify patients with high-risk TIA (ABCD2 ≥6) or minor ischemic stroke (NIHSS ≤5) eligible for DAPT, we excluded patients with atrial fibrillation, anticoagulant use, prior major bleeding, or unknown stroke severity.

Findings

We identified 10,053 potential DAPT-candidates (mean age 72.6 years, 45.2% female, 16.4% with TIA). With advancing age, most vascular risk factors increased. Antiplatelet treatment increased from 31.9% before the event to 95.5% after discharge. Within 1 year following index event, the proportion of patients with ≥1 re-admission increased with age (29.2% in 40–64 year-olds; 47.2% in 85–100 year-olds). All-cause death per 100 person-years was 6.9 (95% CI 6.4–7.4) within 1 year, and highest in the first 30 days (15.2; 95% CI 12.8–18.2). For each year of increased age, the risk of death increased with 3.5% (p = 0.128) in patients 40–64 years and with 11.8% (p < 0.001) in those ≥85 years.

Conclusions

While in theory representing a subset of patients with mild injury, our observational study highlights substantial use of health-care resources and high mortality rates among patients with high-risk TIA or minor ischemic stroke assumed eligible for DAPT.


Safety and Outcome of Decompressive Hemicraniectomy After Recombinant Tissue Plasminogen Activator Thrombolysis for Acute Ischemic Stroke: A Systematic Review

Source: World Neurosurgery


Date of publication: December 2020

Publication type: Journal article

Abstract

Background: Decompressive hemicraniectomy (DH) is widely recommended as a surgical treatment for intractable increased intracranial pressure after malignant cerebral infarction. Many patients given recombinant tissue plasminogen activator (rtPA) develop cerebral edema after reperfusion or failed recanalization. However, the safety and efficacy of DH after rtPA administration remain largely unknown.

Methods: A systematic review was performed using PubMed, Embase, Scopus, Cochrane, and HERDIN. Studies were eligible if they included patients who underwent DH after intravenous thrombolysis for acute ischemic stroke. Unweighted odds ratio (OR) for mortality (primary outcome) and good functional outcome defined as modified Rankin Scale score 0-3 or Glasgow Outcome Scale score 4-5 at 3-6 months (secondary outcome) were compared between the DH + rtPA group and DH alone group.

Results: Four studies with a total of 98 patients undergoing DH + rtPA were compared with 110 patients undergoing DH alone without previous thrombolysis. Age, vascular risk factors, and cause of stroke were comparable between the 2 groups. Pooled analysis showed that mortality and functional outcomes were not statistically different between the DH + rtPA and DH alone groups (OR, 0.56, P = 0.07 and OR, 0.83, P = 0.30, respectively). Likewise, both minor and major hemorrhagic rates were similar between the 2 groups (37.76% vs. 27.27%; P = 0.053).

Conclusions: DH for malignant cerebral infarction after intravenous rtPA administration is a viable treatment option, with a comparable mortality and functional outcome to those who had DH without previous thrombolysis.



Venous and arterial thromboembolic events with immune checkpoint inhibitors: A systematic review

Source: Thrombosis Research



Publication type: Journal article

In a nutshell:

Abstract

Background

Venous (VTEs) and arterial thromboembolic events (ATEs) are causes of morbidity, disability, mortality, and increase in treatment costs in cancer patients. The risk associated with immune checkpoint inhibitors (ICIs) has not yet been clarified. The primary objective of this systematic review was to evaluate the incidence of VTEs and ATEs in patients treated with ICIs as single agents or in combination with other treatments.

Material and methods

Data from retrospective and prospective studies were selected from PubMed, EMBASE, SCOPUS, and The Cochrane Library from inception up to May up to 21st May 2020. All studies had to be in English and use human study participants. The studies were eligible if they provided a number (or rate) of VTEs and ATEs and the size of the population included. The PRISMA guidelines were followed. The data on the incidence of VTEs and ATEs were extracted for each arm, analyzed using random-effects models, and reported as weighted measures.

Results

A total of 20,273 patients from 68 studies were included (median follow-up ranged from a few months up to three years). Overall, there were 390 VTEs and 59 ATEs, with incidence rates of 2.7% (95%CI 1.8%–4%) and 1.1% (95%CI 0.5%–2.1%), respectively. The rate of pulmonary embolism was 1.6% (95%CI 0.7%–3.2%) and deep venous thrombosis was 2.7% (95%CI 1.4%–5.4%). In studies where ICIs were administered with chemotherapy, rates of VTEs were similar to ICI alone arms (2.8% vs 2.5%). The rate of stroke and myocardial infarction were 1.1% (95%CI 0.65%–1.45%) and 0.7% (95%CI 0.15%–1.15%), respectively. In randomized trials, compared with non-ICIs containing arms (e.g. chemotherapy), the relative risk (RR) of VTEs due to ICIs was similar (RR 1.08, 95%CI 0.6–1.9; P = .79).

Conclusions

Thromboembolic events associated with ICIs are relatively rare in cancer patients with an advanced stage of the disease. However, in randomized studies, their incidence is similar to control arms, suggesting that the contributory role of ICIs to the thromboembolic risk in many cancer settings is small.



Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.

Source: Age and Aging




In a nutshell:

Abstract

Background

anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC).

Objective

to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation.

Methods

studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale.

Results

twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98–7.25 versus 3.95, 95% CI: 2.85–10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29–2.15 versus 0.65, 95% CI: 0.29–1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation.

Conclusion

estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.



Multivariable risk scores for predicting short term outcomes for emergency department patients with unexplained syncope: a systematic review

Source: Academic Emergency Medicine




In a nutshell:

Abstract

Objectives

Emergency department patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days.

Methods

We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an emergency department with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals.

Results

We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI 5.3‐10%) experienced an adverse event. A Canadian Syncope Risk Score of 4 or more was associated with a high likelihood of an adverse event (LR score=4 or more 11 [95% CI 8.9‐14). A Canadian Syncope Risk Score of 0 or less (LR Score = 0 or less 0.10 [95% CI 0.07‐0.20]) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk.

Conclusion

Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The Canadian Syncope Risk Score is an accurate validated prediction score for emergency department patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost or outcomes of care is not known.



Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Source: Journal of Clinical Medicine




In a nutshell:

The purpose of this systematic review and meta-analysis is to evaluate the long-term efficacy of Extracorporeal Shock Wave Therapy (ESWT) on reducing lower limb post-stroke spasticity in adults. A systematic electronic search of PubMed/ MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, Ovid MEDLINE(R), and search engine of Google Scholar was performed. Publications that ranged from January 2010 to August 2020, published in English, French, Spanish, Portuguese, and Italian language and available as full texts were eligible for inclusion and they were searched without any restrictions of country. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Two authors screened the references, extracted data, and assessed the risk of bias. The primary outcome was spasticity grade mainly assessed by the Modified Ashworth Scale (MAS). Secondary outcomes were passive range of motion (PROM), pain intensity, electrophysiological parameters, gait assessment, and adverse events. A total of seven recent randomized controlled trials (RCTs) were included in the systematic review and meta-analysis, and a beneficial effect on spasticity was found. The high level of evidence presented in this paper showed that ESWT ameliorates spasticity considering the parameters: MAS: standardized mean difference (SMD) = 0.53; 95% confidence interval (95% CI): (0.07-0.99); Modified Tardieu Scale (MTS): SMD = 0.56; 95% CI: (0.01-1.12); Visual Analogue Scale (VAS): SMD = 0.35; 95% CI: (-0.21-0.91); PROM: SMD = 0.69; 95% CI: (0.20-1.19). ESWT presented long-term efficacy on lower limb post-stroke spasticity, reduced pain intensity, and increased range of motion. The effect of this novel and non-invasive therapy was significant and the intervention did not present adverse events, proving a satisfactory safety profile.



Interventions for improving oral health in people after stroke

Source: Cochrane Library




In a nutshell:

We found low‐ to very low‐quality evidence suggesting that OHC interventions can improve the cleanliness of patient's dentures and stroke survivor and providers' knowledge and attitudes. There is limited low‐quality evidence that selective decontamination gel may be more beneficial than placebo at reducing the incidence of pneumonia. Improvements in the cleanliness of a patient's own teeth was limited. We judged the quality of the evidence included within meta‐analyses to be low or very low quality, and this limits our confidence in the results. We still lack high‐quality evidence of the optimal approach to providing OHC to people after stroke.



Fluoxetine for stroke recovery improvement – the doubleblind, randomised placebo-controlled FOCUS-Poland trial

Source: Polish Journal of Neurology and Neurosurgery



Publication type: Research Article

In a nutshell:

Abstract

Aim of study. The Fluoxetine Or Control Under Supervision (FOCUS)-Poland trial tested in a Polish cohort the hypothesis that fluoxetine improves recovery after stroke.

Clinical rationale for study. Some studies have suggested that fluoxetine may improve functional outcomes after stroke, but these results needed confirmation. Between 2012 and 2014, large clinical trials were initiated by the FOCUS Trial Collaboration. Recently, results from the UK, Sweden, Australia, New Zealand and Vietnam have been published. We here present the results of the FOCUS trial conducted in Poland.

Material and methods. This was a randomised, double-blind, placebo-controlled study based on the FOCUS trial protocol. Patients who had a persisting neurological deficit were randomly assigned 2-15 days after stroke onset to receive for six months either fluoxetine 20 mg/day or a placebo. The primary outcome was functional status measured using the modified Rankin Scale (mRS) at six months after randomisation. Functional status at 12 months was also assessed, as was neurological deficit at six and 12 months. Data was also collected on adverse events.

Results. Between 19 December 2014 and 13 March 2018, 30 patients were given fluoxetine and 31 were given a placebo. For the primary outcome, the distribution across mRS categories was similar for the fluoxetine and placebo groups at six months (common odds ratio 0.88; 95% confidence interval 0.31–2.50; p = 0.81), and there was no difference at 12 months (p = 0.864). There were no differences between groups in stroke recovery or in motor function recovery of the affected hand. There were no significant differences in any other secondary outcomes at six or 12 months. Patients given fluoxetine were less likely than those given the placebo to receive new antidepressant medication within six months (2 [6.67%] vs. 4 [12.90%]).

Conclusions and clinical implications. Consistent with other trials based on the FOCUS protocol, fluoxetine did not improve motor recovery or general stroke outcome at six and 12 months in the Polish cohort studied. However, patients receiving fluoxetine required therapy with additional antidepressant medication less frequently.



Five-Year Risk of Acute Myocardial Infarction After Acute Ischemic Stroke in Korea.

Source: Journal of the AHA



Publication type: Research Article

In a nutshell:

Background The long-term incidence of acute myocardial infarction (AMI) in patients with acute ischemic stroke (AIS) has not been well defined in large cohort studies of various race-ethnic groups. Methods and Results A prospective cohort of patients with AIS who were registered in a multicenter nationwide stroke registry (CRCS-K [Clinical Research Collaboration for Stroke in Korea] registry) was followed up for the occurrence of AMI through a linkage with the National Health Insurance Service claims database. The 5-year cumulative incidence and annual risk were estimated according to predefined demographic subgroups, stroke subtypes, a history of coronary heart disease (CHD), and known risk factors of CHD. A total of 11 720 patients with AIS were studied. The 5-year cumulative incidence of AMI was 2.0%. The annual risk was highest in the first year after the index event (1.1%), followed by a much lower annual risk in the second to fifth years (between 0.16% and 0.27%). Among subgroups, annual risk in the first year was highest in those with a history of CHD (4.1%) compared with those without a history of CHD (0.8%). The small-vessel occlusion subtype had a much lower incidence (0.8%) compared with large-vessel occlusion (2.2%) or cardioembolism (2.4%) subtypes. In the multivariable analysis, history of CHD (hazard ratio, 2.84; 95% CI, 2.01-3.93) was the strongest independent predictor of AMI after AIS. Conclusions The incidence of AMI after AIS in South Korea was relatively low and unexpectedly highest during the first year after stroke. CHD was the most substantial risk factor for AMI after stroke and conferred an approximate 5-fold greater risk.



Urate, Blood Pressure, and Cardiovascular Disease: Evidence From Mendelian Randomization and Meta-Analysis of Clinical Trials

Source: Hypertension



Publication type: Review article

In a nutshell:

Serum urate has been implicated in hypertension and cardiovascular disease, but it is not known whether it is exerting a causal effect. To investigate this, we performed Mendelian randomization analysis using data from UK Biobank, Million Veterans Program and genome-wide association study consortia, and meta-analysis of randomized controlled trials. The main Mendelian randomization analyses showed that every 1-SD increase in genetically predicted serum urate was associated with an increased risk of coronary heart disease (odds ratio, 1.19 [95% CI, 1.10-1.30]; P=4×10-5), peripheral artery disease (1.12 [95% CI, 1.03-1.21]; P=9×10-3), and stroke (1.11 [95% CI, 1.05-1.18]; P=2×10-4). In Mendelian randomization mediation analyses, elevated blood pressure was estimated to mediate approximately one-third of the effect of urate on cardiovascular disease risk. Systematic review and meta-analysis of randomized controlled trials showed a favorable effect of urate-lowering treatment on systolic blood pressure (mean difference, -2.55 mm Hg [95% CI, -4.06 to -1.05]; P=1×10-3) and major adverse cardiovascular events in those with previous cardiovascular disease (odds ratio, 0.40 [95% CI, 0.22-0.73]; P=3×10-3) but no significant effect on major adverse cardiovascular events in all individuals (odds ratio, 0.67 [95% CI, 0.44-1.03]; P=0.07). In summary, these Mendelian randomization and clinical trial data support an effect of higher serum urate on increasing blood pressure, which may mediate a consequent effect on cardiovascular disease risk. High-quality trials are necessary to provide definitive evidence on the specific clinical contexts where urate lowering may be of cardiovascular benefit.



Heterogeneity of diabetes as a risk factor for major adverse cardiovascular events in anticoagulated patients with atrial fibrillation: an analysis of the ARISTOTLE trial

Source: Eur Heart J Cardiovasc Pharmacother.




In a nutshell:

Abstract

Aims: Whether diabetes without insulin therapy is an independent cardiovascular (CV) risk factor in atrial fibrillation (AF) has recently been questioned. We investigated the prognostic relevance of diabetes with or without insulin treatment in patients in the ARISTOTLE trial.

Methods and results: Patients with AF and increased stroke risk randomized to apixaban vs. warfarin were classified according to diabetes status: no diabetes; diabetes on no diabetes medications; diabetes on non-insulin antidiabetic drugs only; or insulin-treated. The associations between such patient subgroups and stroke/systemic embolism (SE), myocardial infarction (MI), and CV death were examined by Cox proportional hazard regression, both unadjusted and adjusted for other prognostic variables. Patients with diabetes were younger and had a higher body mass index. Median CHA2DS2VASc score was 4.0 in patients with diabetes and 3.0 in patients without diabetes. We found no significant difference in stroke/SE incidence across patient subgroups. Compared with no diabetes, only insulin-treated diabetes was significantly associated with higher risk. When adjusted for clinical variables, compared with no diabetes, the hazard ratios (HRs) for MI (95% confidence intervals) were for diabetes on no medication: 1.15 (0.62-2.14); for diabetes on non-insulin antidiabetic drugs: 1.32 (0.90-1.94); for insulin-treated diabetes: 2.34 (1.43-3.82); interaction P = 0.008. HRs for CV death were for diabetes on no medication: 1.19 (0.86-166); for diabetes on non-insulin antidiabetic drugs: 1.12 (0.88-1.42); for insulin-treated diabetes 1.85 (1.36-2.53), interaction P = 0.001.

Conclusion: In anticoagulated patients with AF, a higher risk of MI and CV death is largely confined to diabetes treated with insulin.



Iron chelators for acute stroke



Date of publication: 25 November 2020


In a nutshell:

We identified two eligible RCTs for assessment. We could not demonstrate any benefit for the use of iron chelators in spontaneous intracerebral haemorrhage. The added value of iron‐chelating therapy in people with ischaemic stroke or subarachnoid haemorrhage remains unknown.



Blood pressure targets in adults with hypertension





In a nutshell:

For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.



Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride





In a nutshell:

In white participants, sodium reduction in accordance with the public recommendations resulted in mean arterial pressure (MAP) decrease of about 0.4 mmHg in participants with normal blood pressure and a MAP decrease of about 4 mmHg in participants with hypertension. Weak evidence indicated that these effects may be a little greater in black and Asian participants. The effects of sodium reduction on potential side effects (hormones and lipids) were more consistent than the effect on BP, especially in people with normal BP.



Does coronavirus cause stroke? A look at the current research

Source: Stroke Association



Publication type: Website

In a nutshell:

Since the start of the coronavirus pandemic in early 2020, there have been reports of coronavirus patients also having a stroke. The Stroke Association, health and social care professionals, and researchers in the UK continue to study coronavirus and stroke, and deliver treatment and care for people that have a stroke.

Research has started to reveal which coronavirus patients are more likely to have a stroke. This is important as, if confirmed in larger studies, it can guide how these patients are treated.

Stroke risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases

Source: Neurology



Publication type: Systematic review

In a nutshell:

Objectives: To investigate the hypothesis that strokes occurring in patients with coronavirus disease 2019 (COVID-19) have distinctive features, we investigated stroke risk, clinical phenotypes, and outcomes in this population.

Methods: We performed a systematic search resulting in 10 studies reporting stroke frequency among patients with COVID-19, which were pooled with 1 unpublished series from Canada. We applied random-effects meta-analyses to estimate the proportion of stroke among COVID-19. We performed an additional systematic search for cases series of stroke in patients with COVID-19 (n = 125), and we pooled these data with 35 unpublished cases from Canada, the United States, and Iran. We analyzed clinical characteristics and in-hospital mortality stratified into age groups (<50, 50-70, >70 years). We applied cluster analyses to identify specific clinical phenotypes and their relationship with death.

Results: The proportions of patients with COVID-19 with stroke (1.8%, 95% confidence interval [CI] 0.9%-3.7%) and in-hospital mortality (34.4%, 95% CI 27.2%-42.4%) were exceedingly high. Mortality was 67% lower in patients <50 years of age relative to those >70 years of age (odds ratio [OR] 0.33, 95% CI 0.12-0.94, p = 0.039). Large vessel occlusion was twice as frequent (46.9%) as previously reported and was high across all age groups, even in the absence of risk factors or comorbid conditions. A clinical phenotype characterized by older age, a higher burden of comorbid conditions, and severe COVID-19 respiratory symptoms was associated with the highest in-hospital mortality (58.6%) and a 3 times higher risk of death than the rest of the cohort (OR 3.52, 95% CI 1.53-8.09, p = 0.003).

Conclusions: Stroke is relatively frequent among patients with COVID-19 and has devastating consequences across all ages. The interplay of older age, comorbid conditions, and severity of COVID-19 respiratory symptoms is associated with an extremely elevated mortality.



Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis

Source: J Stroke Cerebrovasc Dis



Publication type: Systematic review and meta-analysis

In a nutshell:

Abstract

Background: The coronavirus disease 2019 (COVID-19) potentially increases the risk of thromboembolism and stroke. Numerous case reports and retrospective cohort studies have been published with mixed characteristics of COVID-19 patients with stroke regarding age, comorbidities, treatment, and outcome. We aimed to depict the frequency and clinical characteristics of COVID-19 patients with stroke.

Methods: PubMed and EMBASE were searched on June 10, 2020, to investigate COVID-19 and stroke through retrospective cross-sectional studies, case series/reports according to PRISMA guidelines. Study-specific estimates were combined using one-group meta-analysis in a random-effects model.

Results: 10 retrospective cohort studies and 16 case series/reports were identified including 183 patients with COVID-19 and stroke. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% ([95% confidential interval (CI)]: [0.6-1.6], I2 = 62.9%). Mean age was 66.6 ([58.4-74.9], I2 = 95.1%), 65.6% was male (61/93 patients). Mean days from symptom onset of COVID-19 to stroke was 8.0 ([4.1-11.9], p< 0.001, I2 = 93.1%). D-dimer was 3.3 μg/mL ([1.7-4.9], I2 = 86.3%), and cryptogenic stroke was most common as etiology at 50.7% ([31.0-70.4] I2 = 64.1%, 39/71patients). Case fatality rate was 44.2% ([27.9-60.5], I2 = 66.7%, 40/100 patients).

Conclusions: This systematic review assessed the frequency and clinical characteristics of stroke in COVID-19 patients. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% and associated with older age and stroke risk factors. Frequent cryptogenic stroke and elevated d-dimer level support increased risk of thromboembolism in COVID-19 associated with high mortality. Further study is needed to elucidate the pathophysiology and prognosis of stroke in COVID-19 to achieve most effective care for this population.

Keywords: COVID-19; Meta-analysis; SARS-CoV2; Systematic review; stroke.



Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis

Source: Frontiers Neurology




In a nutshell:

Abstract

Background: Cardioembolic strokes are common however atrial fibrillation, the most common cause, is often asymptomatic and difficult to detect. There is evidence that infarct topography and volume on magnetic resonance imaging may be associated with specific stroke etiologies. Aim: A systematic review and meta-analysis were undertaken to summarize the available evidence on the association between stroke etiology, infarct topography, and volume. Methods: A systematic review was conducted using Medline (OVID), Embase (OVID), and PubMed databases. Hand searches of the gray literature and of reference lists in relevant articles were also performed. A quality assessment was undertaken, based on the STROBE checklist. For each study, the number of patients with and without a CE source of stroke and infarct topography was collected and outcomes presented as odds ratios (OR) with 95% CI and p-values. Results: Four thousand eight hundred and seventy-three patients with ischemic stroke were included, of whom 1,559 were determined to have a CE source. Bilateral infarcts (OR 3.41; 95% CI 2.20-5.29; p < 0.0001) and multiple territory infarcts (OR 1.57; 95% CI 1.12-2.21; p = 0.009) were more common in patients with a CE source of stroke, than patients without a CE source. Lacunar infarcts (OR 0.49; 95% CI 0.31-0.80; p = 0.004) were more likely to occur in patients without a CE source. No significant difference between the frequency of multiple infarcts (OR 0.96; 95% CI 0.57-1.61; p = 0.87) anterior circulation (OR 1.45; 95% CI 0.83-2.53; p = 0.19) or posterior circulation infarcts (OR 1.06; 95% CI 0.72-1.57; p = 0.75), between the two groups were identified. Three out of four studies examining volume, found a significant association between increased infarct volume and CE source of stroke. A sensitivity analysis with cryptogenic and undetermined stroke sources assumed to be cardioembolic, did not alter the associations observed. Conclusion: The findings of this systematic review and meta-analysis are broadly consistent with previous literature and provide more robust evidence on the association between infarct topography, volume and stroke etiology. Our findings may assist with refining cardiac investigations for patients with cryptogenic stroke, based on infarct topography.



Antiphospholipid Antibody and Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis

Source: Stroke AHA




In a nutshell:

Abstract

Background and purpose: Although aPLs (antiphospholipid antibodies) are associated with thrombotic events, especially in young patients, the role of aPLs in recurrent ischemic strokes (RIS) is unclear. This systematic review and meta-analysis evaluated the association between aPLs and RIS.

Methods: The systematic review was conducted by a computer-assisted search of literature in PubMed, EMBASE, and Cochrane library published in English or Korean from 1990, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Review Manager 5.3 software was used for statistical analyses.

Results: Of the 2272 identified articles, 8 studies were included (2510 subjects; 844 aPL positive). The meta-analysis revealed a relative risk of aPLs for RIS of 1.41 (95% CI, 0.91-2.17; I2=54%). In the subgroup analysis, age <50 years, ethnicity, and type of aPL did not increase the risk of RIS.

Conclusions: We found that aPLs are not an independent predictor for RIS in adults. However, considering the nonstandardized disease criteria, further well-designed prospective trials should be considered to confirm these findings.



Quality of Stroke Patient Information Applied in Randomized Controlled Trials-Literature Review

Source: Frontiers Neurology




In a nutshell:

Abstract

Background: Strokes have a huge impact on patients' quality of life. Although there are potentially effective secondary preventions and treatment options for stroke patients, adherence is mostly low. Low disease and treatment-related knowledge and, consequently, a lack of informed decision-making in stroke patients may contribute to this problem. However, stroke patient information did not seem to have relevant effects on patients' knowledge in randomized controlled trials. One contributing factor may be the lack of thoroughly developed patient information materials. Methods: We aimed to evaluate the quality of patient information materials for stroke patients by using randomized controlled trials, applying quality criteria for evidence-based patient information (EBPI). We conducted a literature search (MEDLINE, Embase, CINAHL, PsycINFO, and CENTRAL). To be included in the review, research had to be randomized controlled trials that provided stroke patient information, were published in English, and had knowledge assessed as the primary endpoint. Authors of primary studies were contacted and asked for information materials applied. Results: We screened 15,507 hits and identified 30 eligible studies. Information materials were available for only eight studies. Analyses revealed that all available materials had important shortcomings concerning EBPI quality criteria [concerning, for example, structural information (e.g., reporting conflicts of interest), content information (e.g., reporting sources of information), or comprehensive descriptions of treatment effects and side effects]. Frequently, treatment effects were reported only narratively without providing absolute numbers, values, or frequencies. Conclusion: Quality of materials differed, but none sufficiently fulfilled EBPI quality criteria. Unsatisfactory trial results concerning patient knowledge and patient involvement in decision-making may at least partially be explained by limitations of the provided materials. Future patient information should consider EBPI quality criteria.



A systematic review of social service and community resource interventions following stroke

Source: Disabil Rehabil




In a nutshell:

Abstract

Purpose: Finding and accessing social services and community resources are a challenge for stroke survivors and care partners. The purpose of this systematic review was to identify and review interventions that aimed to increase access and use of such services and resources post stroke.

Method: A systematic review of the published literature was performed using MEDLINE, CINAHL, PsycINFO, and ProQuest Nursing and Allied Health (January 2008 to May 2020). Studies were included if they were quantitative designs and reported on outcomes of interventions addressing post-stroke access to social services or community resources. Results were synthesised narratively.

Results: 3566 titles and abstracts were reviewed. Ten articles met the inclusion criteria. The interventions included in this review varied in terms of target group, timing, and type of support provided (passive or active tailored information provision, referral service, navigation assistance). Outcome measures, for social service and community resource access, included discharge preparedness measures, service counts, observations, satisfaction evaluations, interviews, and open-ended questions.

Conclusion: Overall, interventions demonstrated some improvements in information received and access to social services and community resources following stroke. Future research should focus on carrying out high quality studies that examine the effectiveness of various social service and community resource interventions, and on setting valid and reliable outcome measures. IMPLICATIONS FOR REHABILITATION Stroke survivors and care partners have unmet social service and community resource needs. Stroke survivors and care partners can benefit from interventions that provide information, referrals, and ongoing support to access services and resources. Clearly identifying social service and community resource needs is important for tailoring interventions to individual situations. Interventions should ideally be provided throughout the hospital stay, in acute care and rehabilitation, and continue on in the community.



The Association of Overt and Subclinical Hyperthyroidism with the Risk of Cardiovascular Events and Cardiovascular Mortality: Meta-Analysis and Systematic Review of Cohort Studies

Source: Endocrin Metabol (Seoul)




In a nutshell:

Abstract

Background: Whether hyperthyroidism is an independent risk factor for cardiovascular events remains controversial. We aimed to evaluate the association of overt and subclinical hyperthyroidism with the risk of ischemic heart disease (IHD), stroke, heart failure, and cardiovascular mortality.

Methods: Studies regarding the association between hyperthyroidism and cardiovascular events were searched on PubMed and Embase databases. The cardiovascular disease (CVD) risk was classified as high and low, based on pre-existing diseases, including history of coronary, cerebral, or peripheral artery disease; heart failure; atrial fibrillation; diabetes mellitus; or chronic kidney disease.

Results: Thirty-seven cohort studies were included in this meta-analysis. The pooled hazard ratio for subjects with overt hyperthyroidism compared with the control group was 1.11 (95% confidence interval [CI], 1.03 to 1.19) for IHD, 1.35 (95% CI, 1.03 to 1.75) for stroke, and 1.20 (95% CI, 1.00 to 1.46) for cardiovascular mortality. For subjects with subclinical hyperthyroidism, the pooled hazard ratio was 1.24 (95% CI, 1.07 to 1.45) for IHD, when compared with the control group. Subgroup analysis by CVD risk showed that the risk of stroke in overt hyperthyroidism was increased in the low CVD risk group; however, these association was not observed in the high CVD risk group. Similarly, the risk of IHD in subjects with subclinical hyperthyroidism was significantly increased in the low CVD risk group.

Conclusion: Overt hyperthyroidism is associated with increased risk of IHD, stroke, and cardiovascular mortality, and subclinical hyperthyroidism is associated with increased risk of IHD. These associations were particularly observed in the low risk CVD group without underlying CVD.



Scientists test new “algorithm" to help prevent heart attacks

Source: BHF



Publication type: News article

In a nutshell:

Researchers in Scotland are leading a new technology project which they hope will help identify patients at risk of heart attack before symptoms develop, potentially saving thousands of lives.

Length of publication: News article

Symptoms of depression linked to increased risk of heart disease and stroke

Source: BHF




In a nutshell:

People who experience symptoms of depression are more likely to go on to develop heart disease or suffer a stroke than those who report good mental health, according to research we part-funded and published today in JAMA.


People with heart and circulatory conditions at higher risk of dying from flu

Source: BHF




In a nutshell:

People living with heart and circulatory conditions, such as chronic heart disease, angina, or people who have had a stroke, are 11 times more likely to die of the flu.


Trial resumes to prevent dementia after a stroke

Source: BHF




In a nutshell:

Researchers in Edinburgh have resumed a new clinical trial which they hope could lead to treatments to prevent some cases of dementia after a stroke.


Scientists discover why the heart slows down at night

Source: BHF




In a nutshell:

A more than 90-year-old consensus on the mechanisms which regulate the day-night rhythm in heart rate has been fundamentally challenged by research led by the University of Manchester.


The BHF's research highlights of 2020

Source: BHF




In a nutshell:

What a year it's been for our community of researchers. Not only have they continued their life-saving research into heart and circulatory diseases, but some redirected their expertise to join the fight against coronavirus. Let’s take a moment to reflect on some of the BHF’s research highlights in 2020.


THROMBOLYSIS IN UNKNOWN STROKE ONSET: BROADENING THE HORIZON WITH ADVANCED BRAIN IMAGING

Source: ESO




In a nutshell:

Thrombolysis in unknown stroke onset: broadening the horizon with advanced brain imaging.

A great opportunity of the virtual ESO-WSO 2020 conference is the possibility to rewatch and analyse the data presented for large clinical trials that will likely have a big impact on our practice. There were a lot of impressions on one of the most highlighted post in Twitter, made by @ESOStroke about Götz Thomalla’s presentation on the meta-analysis of 4 thrombolysis trials in ischemic stroke (IS) patients with unknown symptoms onset: WAKE-UP, EXTEND, THAWS and ECASS-4.


stroke prevention in atrial fibrillation: looking forward · web viewantiplatelet treatment...

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