Impact of Baseline Features and Risk Factor Control on Cognitive Function in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

2019 ◽  
Vol 47 (1-2) ◽  
pp. 24-31 ◽  
Author(s):  
Tanya N. Turan ◽  
Sami Al Kasab ◽  
Alison Smock ◽  
George Cotsonis ◽  
David Bachman ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Cognitive Impairment ◽  
Cognitive Function ◽  
Medical Management ◽  
Physical Inactivity ◽  
Recurrent Stroke ◽  
Older Age ◽  
Aggressive Medical Management

Background: Cerebrovascular disease is an important cause of cognitive impairment. The aim of this study is to report the relationship between cognitive function and risk factors at baseline and during follow-up in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial. Methods: Subjects in the SAMMPRIS trial were included in this study. In order to have an assessment of cognitive function independent of stroke, patients with a stroke as a qualifying event whose deficits included aphasia or neglect were excluded from these analyses as were those with a cerebrovascular event during follow-up. The Montreal Cognitive Assessment (MoCA) score was used to assess cognitive impairment at baseline, 4 months, 12 months and closeout. Cognitive impairment was defined as MoCA < 26. A multivariate analysis was performed to determine what risk factors were independent predictors of cognitive function at baseline, 12 months and closeout. Among patients randomized to aggressive medical management only, the percentage of patients with cognitive impairment was compared between patients in versus out of target for each risk factor at 12 months and closeout. Results: Of the 451 patients in SAMMPRIS, 371 patients met the inclusion criteria. MoCA < 26 was present in 55% at baseline. Older age and physical inactivity were associated with cognitive impairment at baseline. Older age, non-white race, lower baseline body mass index, and baseline cognitive impairment were associated with cognitive impairment at 12 months. In the aggressive medical management group, at 12 months, physical inactivity during follow-up was the strongest risk factor associated with cognitive impairment. Conclusion: Cognitive impairment is common in patients with severe symptomatic intracranial atherosclerosis. Physical inactivity at baseline and during follow-up is a strong predictor of cognitive impairment.

Abstract T MP105: Relationship Between Compliance With the Lifestyle Modification Program and Risk Factor Control in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tanya N Turan ◽  
Azhar Nizam ◽  
Michael J Lynn ◽  
Jean Montgomery ◽  
Colin P Derdeyn ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Medical Management ◽  
Lifestyle Modification ◽  
Recurrent Stroke ◽  
Risk Factor Control ◽  
Chi Square ◽  
Lifestyle Modification Program ◽  
Aggressive Medical Management

Background and Purpose: SAMMPRIS was the first vascular disease prevention trial to provide a commercially available lifestyle modification program to subjects to enhance risk factor control. We sought to determine the relationship between compliance with the lifestyle modification program and risk factor control in SAMMPRIS. Methods: SAMMPRIS aggressive medical management included a telephonic lifestyle modification program provided free of charge to all subjects (n=451) during their participation in the study. Subjects with < 3 expected lifestyle coaching calls were excluded from these analyses. Subjects with ≥ 78.5% of calls (median % of completed/expected calls) were considered Compliant (n=201). Subjects with < 78.5% and those who refused to participate were considered Noncompliant (n=200). Mean risk factor values or % in-target for each risk factor were compared between Compliant vs. Noncompliant subjects, using t-tests and chi-square tests. Risk factor changes from baseline to follow-up were compared between the groups to account for baseline differences between the groups. Results: As shown in the figure, Compliant subjects had better risk factor control throughout follow-up for LDL, SBP, HgA1c, non-HDL, non-smoking, and exercise than Noncompliant subjects, but there was no difference for BMI. Compliant subjects also had better control of LDL, non-HDL, and HgA1c at baseline. Both groups had some improvement in risk factors throughout the study (except for BMI), but after adjusting for baseline differences between the groups, Compliant subjects had a greater change from baseline than Noncompliant subjects for SBP at 24 months and HgA1c at 6 months. Conclusions: SAMMPRIS subjects who were compliant with the lifestyle modification program had better risk factor control during the study for almost all risk factors.

Abstract 141: Impact of an Aggressive Medical Management Protocol on Early Risk Factor Measures in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) Trial

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tanya N Turan ◽  
Azhar Nizam ◽  
Michael J Lynn ◽  
Colin P Derdeyn ◽  
David Fiorella ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Medical Management ◽  
Intracranial Stenosis ◽  
Patient Specific ◽  
Early Risk ◽  
Aggressive Medical Management ◽  
The Impact ◽  
Early Risk Factor

Purpose: SAMMPRIS is the first stroke prevention trial to include protocol-driven aggressive management of multiple vascular risk factors. We sought to determine the impact of this protocol on early risk factor control in the trial. Materials and Methods: SAMMPRIS randomized 451 patients with symptomatic 70%-99% intracranial stenosis to aggressive medical management or stenting plus aggressive medical management at 50 USA sites. For the primary risk factor targets (SBP < 140 mm/Hg (<130 if diabetic) and LDL < 70 mg/dL), the study neurologists follow medication titration algorithms and risk factor medications are provided to the patients. Secondary risk factors (diabetes, non-HDL, weight, exercise, and smoking cessation) are managed with assistance from the patient’s primary care physician and a lifestyle modification program (provided). Sites receive patient-specific recommendations and feedback to improve performance. Follow-up continues, but the 30-day data are final. We compared baseline to 30-day risk factor measures using paired t-tests for means and McNemar tests for percentages. Results: The differences in risk factor measures between baseline and 30 days are shown in Table 1. Conclusions: The SAMMPRIS protocol resulted in major improvements in controlling most risk factors within 30 days of enrollment, which may have contributed to the lower than expected 30 day stroke rate in the medical group (5.8%). However, the durability of this approach over time will be determined by additional follow-up.

Abstract W P130: Relationship Between Risk Factor Control and Vascular Events in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tanya N Turan ◽  
Azhar Nizam ◽  
Michael J Lynn ◽  
Jean Montgomery ◽  
Colin P Derdeyn ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Medical Management ◽  
Lower Risk ◽  
Intracranial Stenosis ◽  
Vascular Events ◽  
Risk Factor Control ◽  
Increased Risk ◽  
Aggressive Medical Management

Background and Purpose: Symptomatic intracranial stenosis patients with poorly controlled cholesterol and blood pressure had an increased risk of vascular events in WASID. Therefore, SAMMPRIS aggressive medical management protocols targeted these risk factors. We sought to determine if intensive risk factor control in SAMMPRIS resulted in lower risk of vascular events during follow-up. Methods: Data on 227 SAMMPRIS patients randomized to aggressive medical management alone were used for these analyses. Vascular risk factors were recorded at baseline, 30 days, and every 4 months. Additional follow-up and close-out visit data were also included. For each patient, values for all risk factor measures (from baseline until the time of an event) were averaged and dichotomized based on the risk factor target. Time to event curves for a vascular event (stroke, MI, and vascular death) were compared between subjects with and without risk factor control using the log-rank test and hazard ratios were calculated with Cox proportional hazards regression. Results: The univariate analyses are shown in the table. Subjects with mean follow-up SBP < 140 mm Hg (< 130 for diabetics), LDL < 70 mg/dL, and at least moderate exercise had lower risk of vascular events compared to those who did not achieve those targets. Control of other risk factors (HgA1c, smoking, non-HDL, and Body Mass Index) did not have a significant impact on outcome. Conclusions: Well controlled SBP and LDL during follow-up were predictors of lower vascular events in SAMMPRIS, confirming that SBP and LDL should be aggressively treated in patients with intracranial stenosis to prevent future vascular events. Exercise participation was also associated with fewer vascular events and should be strongly encouraged.

Long-Term Cognitive Decline After Stroke: An Individual Participant Data Meta-Analysis

Stroke ◽  
2021 ◽  
Author(s):  
Jessica W. Lo ◽  
John D. Crawford ◽  
David W. Desmond ◽  
Hee-Joon Bae ◽  
Jae-Sung Lim ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cognitive Function ◽  
Cognitive Decline ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Older Age ◽  
Individual Participant Data ◽  
Individual Participant ◽  
Global Cognition

Background and Purpose: Poststroke cognitive impairment is common, but the trajectory and magnitude of cognitive decline after stroke is unclear. We examined the course and determinants of cognitive change after stroke using individual participant data from the Stroke and Cognition Consortium. Methods: Nine longitudinal hospital-based cohorts from 7 countries were included. Neuropsychological test scores and normative data were used to calculate standardized scores for global cognition and 5 cognitive domains. One-step individual participant data meta-analysis was used to examine the rate of change in cognitive function and risk factors for cognitive decline after stroke. Stroke-free controls were included to examine rate differences. Based on the literature and our own data that showed short-term improvement in cognitive function after stroke, key analyses were restricted to the period beginning 1-year poststroke to focus on its long-term effects. Results: A total of 1488 patients (mean age, 66.3 years; SD, 11.1; 98% ischemic stroke) were followed for a median of 2.68 years (25th–75th percentile: 1.21–4.14 years). After an initial period of improvement through up to 1-year poststroke, decline was seen in global cognition and all domains except executive function after adjusting for age, sex, education, vascular risk factors, and stroke characteristics (−0.053 SD/year [95% CI, −0.073 to −0.033]; P <0.001 for global cognition). Recurrent stroke and older age were associated with faster decline. Decline was significantly faster in patients with stroke compared with controls (difference=−0.078 SD/year [95% CI, −0.11 to −0.045]; P <0.001 for global cognition in a subgroup analysis). Conclusions: Patients with stroke experience cognitive decline that is faster than that of stroke-free controls from 1 to 3 years after onset. An increased rate of decline is associated with older age and recurrent stroke.

scholarly journals Sickle Cell Trait and Risk of Cognitive Impairment in African Americans: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1322-1322 ◽  
Author(s):  
Christina Cahill ◽  
Marguerite Ryan Irvin ◽  
Neil A Zakai ◽  
Rakhi P. Naik ◽  
Leslie McClure ◽  
...  
Keyword(s):  
Risk Factor ◽  
Cognitive Impairment ◽  
Cognitive Function ◽  
African Americans ◽  
Kidney Disease ◽  
Racial Differences ◽  
Odds Ratio ◽  
Sickle Cell Trait ◽  
Function Testing

Abstract Background:Sickle cell anemia (SCA) has been associated with cognitive dysfunction, perhaps in part due to vascular occlusive disease. Increasing evidence suggests that some complications of SCA might also affect those with sickle cell trait (SCT), including chronic and end-stage kidney disease and venous thromboembolism. Thus, SCT may not be a benign condition. Based on data that SCA may influence cognition, we hypothesized that SCT is a risk factor for cognitive impairment in African-Americans. Methods: Participants were African-American adults aged 45 and older from a national prospective cohort study of 30,239 white and black Americans; the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. The study collected extensive baseline risk factor data, and conducted baseline and annual cognitive function testing using the Six-Item Screener (SIS), a validated telephone-administered instrument for global cognitive function that yields a score from 0 to 6. Participants included in this analysis were African-Americans without SCA who had available data on baseline and at least one follow up SIS, SCT genotyping and principal components of ancestry. Participants with baseline SIS ≤4 were excluded as having prevalent impairment. Incident cognitive impairment was defined as having a score at the most recent assessment of ≤4. Logistic regression was used to model associations of SCT with incident cognitive impairment, adjusted for risk factors (listed in table footnote). Results:Among 5,507 participants (mean age 63.5), 731 developed incident cognitive impairment with average follow up of 8.1 years. Those with incident cognitive impairment were more likely to be male with prebaseline history of cardiovascular diseases, diabetes, hypertension and dyslipidemia, and had lower income and education. They were slightly more likely to have SCT (7.9% vs 7.3%). In sequentially adjusted models (table), there was no association of SCT with incident cognitive impairment, with a fully adjusted odds ratio of 1.16 (95% CI 0.79-1.71). There were no significant differences in this odds ratio by age, diabetes, hypertension, dyslipidemia, cardiovascular disease, kidney disease or smoking status (p for interaction with SCT all >0.4). Conclusion:In this prospectively followed general population cohort of middle-aged and older adults with longitudinal cognitive function testing, SCT was not associated with increased risk of incident cognitive impairment overall or in various high-risk subgroups. These findings suggest that unlike in SCA, SCT does not result in chronic cerebrovascular dysfunction. To confirm and extend these findings, further work is needed on associations of SCT with specific domains of cognitive function. Disclosures No relevant conflicts of interest to declare.

Abstract 2: Tolerability and Medication Requirements of Aggressive Medical Management in SAMMPRIS

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sami Al Kasab ◽  
Chirantan Banerjee ◽  
Michael Lynn ◽  
George A Cotsonis ◽  
Azhar Nizam ◽  
...  
Keyword(s):  
Risk Factor ◽  
Medical Management ◽  
Postural Hypotension ◽  
Descriptive Statistics ◽  
Lipid Lowering ◽  
Multiple Risk Factor ◽  
Secondary Stroke Prevention ◽  
Aggressive Medical Management ◽  
Event Rates

Introduction: SAMMPRIS was the first secondary stroke prevention trial to employ multi-modal protocol-driven aggressive medical management (AMM). Achievement of target SBP, LDL and physical activity were predictors of lower vascular event rates. We sought to determine the tolerability and medication requirements related to AMM. Methods: Medications and adverse events (AEs) in all 451 SAMMPRIS patients were recorded by sites at baseline, 30 days, 4 monthly visits, and closeout. Start and stop dates were recorded for each medication and AE, with AEs classified by the site as possibly, probably, definitely, or unrelated to risk factor treatment. AEs were adjudicated centrally by consensus of 3 neurologists after the trial ended. Standard descriptive statistics were used. Results: As Table 1 shows, most subjects were on statins and BP medications at baseline. The use of rosuvastatin, which was donated for the trial, increased during follow-up. ACE inhibitors were the most commonly used BP medication. AEs related to BP medications (e.g. standing BP drop > 15mm Hg or postural hypotension) occurred in 240 (53.2%) patients at any point in the trial (including baseline), of which 123 (27.3%) were symptomatic. Syncope occurred in 11 patients, with 3 considered probably or definitely related to study treatment. AEs related to lipid lowering medications occurred in 18.8% patients, 16.6% of which were myopathy symptoms and 1.3% were AST/ALT > 3 times normal, and there were no reported cases of rhabdomyolysis. AEs related to other risk factor treatments occurred in 17.5% patients (e.g. hypoglycemia secondary to glipizide). Conclusion: In the SAMMPRIS trial, AMM required the use of multiple risk factor medications and was well tolerated by most patients, with AE rates similar to SPS3 and SPARCL.

Revisiting Angioplasty Without Stenting for Symptomatic Intracranial Atherosclerotic Stenosis After the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Study

Neurosurgery ◽  
2012 ◽  
Vol 71 (6) ◽  
pp. 1103-1110 ◽  
Author(s):  
Travis M. Dumont ◽  
Peter Kan ◽  
Kenneth V. Snyder ◽  
L. Nelson Hopkins ◽  
Adnan H. Siddiqui ◽  
...  
Keyword(s):  
Medical Management ◽  
Recurrent Stroke ◽  
Case Series ◽  
Intracranial Stenosis ◽  
Event Free Survival ◽  
Ischemic Event ◽  
Free Survival ◽  
One Year ◽  
Aggressive Medical Management

ABSTRACT BACKGROUND: The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study stopped recruiting patients because of higher-than-expected perioperative morbidity of primary stenting in patients with symptomatic intracranial stenosis. An alternative treatment, submaximal angioplasty without stenting, performed concurrently with SAMMPRIS, may offer revascularization benefits with a lower incidence of stenting-related risks. OBJECTIVE: To present the results of a consecutive case series of primary submaximal angioplasty procedures performed for symptomatic severe atherosclerotic intracranial stenosis refractory to medical treatment. METHODS: A database review identified primary submaximal angioplasty procedures performed in 41 patients for the treatment of &gt;70% intracranial stenosis associated with an acute, symptomatic ischemic event in the distribution of the diseased vessel. For results analysis, 30-day events were reported as a percentage of patients treated. One-year periprocedural and ischemic event--free survival was reported as a percentage of all patients treated and displayed graphically with a Kaplan-Meier survival curve. RESULTS: Three events in 41 patients included 1 intraprocedural vessel perforation, 1 reperfusion hemorrhage &lt; 24 hours postoperatively, and 1 transient ischemic attack 3 months postprocedurally (30-day event rate, 2 of 41, 4.9%). Median clinical follow-up duration after submaximal angioplasty was 19 months, with ≥ 1 year of follow-up available for 32 patients. One-year perioperative and ischemic event-free survival was high (29 of 32 patients, 91%). CONCLUSION: In this series, periprocedural safety of submaximal angioplasty in the setting of acute, symptomatic atherosclerotic intracranial stenosis was demonstrated. Although direct comparison is impossible because many patients were ineligible for stenting procedures, the complication profile compares favorably with rates of identically defined event-free survival for patients randomized to the medical (88%) and surgical (77%) arms of SAMMPRIS despite the absence of aggressive medical management.

Abstract WP177: Retinal Nerve Fiber Layer Thickness and Risk Factors of Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Dandan Wang ◽  
Yang Li ◽  
Yong Zhou ◽  
Shouling Wu ◽  
Wenbin Wei ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cognitive Impairment ◽  
Nerve Fiber ◽  
Retinal Nerve Fiber Layer ◽  
Older Age ◽  
Fiber Layer ◽  
Nerve Fiber Layer ◽  
Rnfl Thickness ◽  
Male Sex

Background and Purpose: We aimed to find the relationship between retinal nerve fiber layer (RNFL) thickness and the relevant risk factors of different stroke subtypes of TOAST classification, in order to make a better primary prevention of stroke. Method: The study population came from the first follow- up of the Asymptomatic Polyvascular Abnormalities Community study (APAC) population. We finished the questionnaire of epidemiological information and medical history during the baseline time, and finished the physical and laboratory examination, transcranial doppler, carotid ultrasound, cognitive functional scale and ophthalmological optical coherence tomography (OCT) examination to measure the thickness of RNFL and whether there exists intracranial artery stenosis (ICAS), extracranial artery stenosis (ECAS) or cognitive impairment. Then we discuss the association between RNFL thickness and the risk factors of stroke mentioned above. Results: We included 5440 participants at baseline and 3376 finished the follow- up eventually. The average thickness of RNFL was 101.89± 10.53 μm. As RNFL became thinner, the percentage of older age, male sex and hypertension became higher (P<0.001). We also found out that ICAS and ECAS, especially ECAS increased as RNFL become thinner (OR:0.982,95% CI:0.969- 0.996,P= 0.011), and the severity of ECAS became worse when RNFL was thinner (P=0.001), and retinal central arteriolar was narrower (P=0.003). What is more, RNFL thickness is associated with cognitive impairment as well (P< 0.05). Conclusion: The thickness of RNFL is associated with stroke risk factors, such as older age, male sex and hypertension. As RNFL became thinner, the prevalence of ICAS and ECAS, which are the main cause of LAA stroke, became higher, and the severity of ECAS became worse. The thinner RNFL was also relevant with cognitive impairment, which is common in the SAO stroke. The results provide a new point of view on stroke classification and prevention.

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