Abstract 140: Long-term disability after lacunar stroke: Secondary Prevention of Small Subcortical Stroke Study

Background: Long-term disability after lacunar stroke is under-studied. We hypothesized that vascular and demographic risk factors predict worsening disability after recovery from lacunar stroke, even in the absence of recurrent stroke. Methods: The Secondary Prevention of Small Subcortical Stroke Study is a clinical trial in lacunar stroke patients with annual assessments of disability with the Older Americans Resources and Survey Instrumental Activities of Daily Living (IADL) scale (range 0-14), measuring 7 IADLs. Generalized estimating equations were used to model the likelihood of disability (IADL score <14) over time, adjusting for demographics, medical risk factors, cognitive and mood factors, and region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile (<55, 55-63, 63-72, ≥72 years), and the final model excluded non-significant terms. Results: Among 2820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 51% White, 32% Hispanic, 36% had some college education, 36% had diabetes, 90% had hypertension, and 10% had prior stroke. Mean follow-up was 3.5 years. Mean IADL score at 3 months was 12.5 (SD 2.5), and 43% were disabled. In multivariable models, female sex (OR 1.5, 95% CI 1.3-1.8), diabetes (1.52, 1.30-1.75), current smoking (1.28, 1.06-1.54), non-regular alcohol use (1.6, 1.4-1.9), prior stroke (1.61, 1.28-2.00), cognitive assessment screening instrument score (0.98 per point, 0.97-0.98), and depression (1.79, 1.49-2.17) were associated with disability. The youngest age quartile had decreased odds of disability over time (OR 0.56 per year, 95% CI 0.36-0.91), whereas the oldest age quartile had increased odds (1.33, 0.83-2.22). There was heterogeneity by region (p<0.0001): Americans and Latin Americans had 2.5-fold greater odds of disability per year compared to Spaniards. Conclusion: In lacunar stroke patients, older age predicted worsening long-term disability, even without recurrent stroke. Worse long-term function was associated with vascular risk factors and prior stroke, and regional differences may have been due to geographic variations in health care delivery or scale interpretation.

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The Relationship Between Glucose Control and Cognitive Function in People With Diabetes After a Lacunar Stroke

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgab022 ◽

2021 ◽

Author(s):

Tali Cukierman-Yaffe ◽

Leslie A McClure ◽

Thomas Risoli ◽

Jackie Bosch ◽

Mike Sharma ◽

...

Keyword(s):

Risk Factors ◽

Cognitive Function ◽

Cognitive Dysfunction ◽

Glucose Control ◽

Lacunar Stroke ◽

Stroke Patients ◽

Patients With Diabetes ◽

The Relationship ◽

Over Time

Abstract Context Lacunar strokes and diabetes are risk factors for cognitive dysfunction. Elucidating modifiable risk factors for cognitive dysfunction has great public health implications. One factor may be glycemic status, as measured by glycated hemoglobin (A1c). Objective The aim of this study was to assess the relationship between A1c and cognitive function in lacunar stroke patients with diabetes. Methods The effect of baseline and follow-up A1c on the baseline and the change in Cognitive Assessment Screening Instrument (CASI) score over time among participants with a median of 2 cognitive assessments (range, 1-5) was examined in 942 individuals with diabetes and a lacunar stroke who participated in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (ClinicalTrials.gov No. NCT00059306). Results Every 1% higher baseline A1c was associated with a 0.06 lower standardized CASI z score (95% CI, –0.101 to –0.018). Higher baseline A1c values were associated with lower CASI z scores over time (P for interaction = .037). A 1% increase in A1c over time corresponded with a CASI score decrease of 0.021 (95% CI, –0.0043 to –0.038) during follow-up. All these remained statistically significant after adjustment for age, sex, education, race, depression, hypertension, hyperlipidemia, body mass index, cardiovascular disease, obstructive sleep apnea, diabetic retinopathy, nephropathy insulin use, and white-matter abnormalities. Conclusion This analysis of lacunar stroke patients with diabetes demonstrates a relationship between A1c and change in cognitive scores over time. Intervention studies are needed to delineate whether better glucose control could slow the rate of cognitive decline in this high-risk population.

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Abstract P218: Long-term Risk Of Recurrent Stroke After Ischemic Stroke Among Younger Adults Under 55 Years Of Age, Sweden

Circulation ◽

10.1161/circ.129.suppl_1.p218 ◽

2014 ◽

Vol 129 (suppl_1) ◽

Author(s):

Kok Wai Giang ◽

Lena Björck ◽

Tatiana Zverkova Sandström ◽

Christina-Heden Ståhl ◽

Kjell Torén ◽

...

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Recurrent Stroke ◽

Cumulative Risk ◽

First Year ◽

Younger Adults ◽

Men And Women ◽

Index Stroke ◽

Over Time

Purpose: The purpose of the present study was to investigate the 4-year risk of recurrent stroke among patients below 55 years with a first ischemic stroke (IS), 1987-2006. Methods: All men and women (17,149 cases) aged 18-54 years who survived at least 28 days after a first IS were identified in the Swedish Inpatient register (IPR) from 1987 until 2006. All patients were followed-up at 1 year, 2 years, 3 years and 4 years for a first recurrent stroke after index event. Results: From 1987 to 2006 a total of 1808 first recurrent stroke were identified. Long-term risk of a first recurrent stroke declined over time in both men and women. Among men, the absolute 4-year cumulative risk of a recurrent stroke decreased from 17.5% (95% CI 15.7%-19.4%) to 8.8% (95% CI, 7.7%-10.0%) from the first to the last 5-year period. Corresponding result for women was 15.6% (95% CI, 13.3%-18.2%) and 6.0% (95% CI, 4.9%-7.3%). Despite an overall decrease, the risk of a recurrent stroke was highest during the first year after index stroke (men=3.9%, 95% CI, 3.3%-4.8%, women=2.9%, 95% CI, 2.2%-3.8%). Conclusions: Over the 20-year period, the 4-year cumulative risk of a first recurrent stroke decreased over time. For both men and women the risk was greatest during the first year, emphasizing the importance of early secondary prevention in young stroke victims.

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Abstract T P268: Medication Persistence and Risk for Hospital Readmission in Stroke Patients

Stroke ◽

10.1161/str.46.suppl_1.tp268 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Sangwon Han ◽

Martinson Arnan ◽

Cheryl Bushnell

Keyword(s):

At Risk ◽

Secondary Prevention ◽

Recurrent Stroke ◽

Statistical Tests ◽

Multivariate Logistic Regression Model ◽

Stroke Recurrence ◽

Limited Information ◽

Medication Persistence ◽

Stroke Patients ◽

Prior Stroke

Background/Objectives: In patients with stroke/TIA, low persistence with hypertension medications increases the risk of stroke recurrence, but there is limited information on medication persistence and readmission. Our aim was to determine whether secondary prevention medication persistence after discharge was associated with readmission at 30 and 90 days in stroke patients. Methods: We enrolled patients discharged home with ischemic (IS) or hemorrhagic stroke (HS) or TIA from October 2012 to February 2014 in the TRAnsition Coaching for Stroke (TRACS). Patients were contacted by telephone between 2 and 30 days for coaching, and 90 days after hospital discharge for outcomes. Medications at discharge were compared to those after discharge by phone or follow-up clinic visit to ascertain stroke prevention medication persistence. Readmission was ascertained using the medical records at the discharge hospital. Statistical tests were performed to assess factors associated with medication persistence and also with all cause and stroke readmission at 30 and 90 days. Results: A total of 142 patients were enrolled (108 IS, 13 HS, and 21 TIA patients); mean age 63.6 ± 13.1 yrs and 52.8% women. Overall medication persistence was 80.3% at 3 months. All cause readmission (ACR) at 30 days was 8.5% (n=12); 4.2% (n=6) due to recurrent stroke/TIA (STR). ACR at 90 days was 18.3% (n=26); 7.0% (n=10) with STR. Multivariate logistic regression model showed that prior hospitalization was associated with ACR at 30 days and CAD, and female sex with ACR at 90 days (Table). Prior stroke was associated with STR at 30 and 90 days (Table). There was a trend toward lower medication persistence (60.0% vs 81.8%, p=0.095) in those with STR at 90 days. Conclusions: In patients discharged with stroke, women and patients with CAD are at risk for ACR and those with prior stroke are at risk for STR, which represents the 3rd event. Poor secondary prevention medication persistence may be a potential risk factor for STR.

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Abstract T P231: Does Intraventricular Hemorrhage Lead to a Normal Pressure Hydrocephalus-Like Syndrome?

Stroke ◽

10.1161/str.45.suppl_1.tp231 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Andrew J Kruger ◽

Matthew Flaherty ◽

Padmini Sekar ◽

Mary Haverbusch ◽

Charles J Moomaw ◽

...

Keyword(s):

Risk Factors ◽

Normal Pressure Hydrocephalus ◽

Barthel Index ◽

Intraventricular Hemorrhage ◽

Normal Pressure ◽

Stroke Study ◽

Increased Risk ◽

Independent Risk Factors ◽

Poor Outcomes

Background: Intracerebral hemorrhage (ICH) has the highest short and long-term morbidity and mortality rates of stroke subtypes. While increased intracranial pressure due to the presence of intraventricular hemorrhage (IVH) may relate to early poor outcomes, the mechanism of reduced 3-month outcome with IVH is unclear. We hypothesized that IVH may cause symptoms similar to normal pressure hydrocephalus (NPH), specifically urinary incontinence and gait disturbance. Methods: We used interviewed cases from the Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study (7/1/08-12/31/12) that had 3-month follow-ups available. CT images were analyzed for ICH volume and location, and IVH presence and volume. Incontinence and dysmobility were defined by Barthel Index at 3 months. We chose a Barthel Index score of bladder less than 10 and mobility less than 15 to define incontinence and dysmobility, respectively. Multivariate analysis was used to assess independent risk factors for incontinence and dysmobility. ICH and IVH volumes were log transformed because of non-normal distributions. Results: Barthel Index was recorded for 308 ICH subjects, of whom 106 (34.4%) had IVH. Presence of IVH was independently associated with both incontinence (OR 2.7; 95% CI 1.4-5.2; p=.003) and dysmobility (OR 2.5; 95% CI 1.4-4.8; p=.003). The Table shows that increasing IVH volume was also independently associated with both incontinence and dysmobility after controlling for ICH location, ICH volume, age, baseline mRS, and admission GCS. Conclusion: Our data show that patients with IVH after ICH are at an increased risk for developing the NPH-like symptoms of incontinence and dysmobility. This may explain the worse long-term outcomes of patients who survive ICH with IVH than those who had ICH alone. Future studies are needed to confirm this finding, and to determine the effect of IVH interventions such as shunt or intraventricular thrombolysis.

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

Stroke ◽

10.1161/strokeaha.121.035796 ◽

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.

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Abstract P132: Clinical Outcomes In Ischemic Stroke Patients With Uncontrolled Hypertension

Hypertension ◽

10.1161/hyp.78.suppl_1.p132 ◽

2021 ◽

Vol 78 (Suppl_1) ◽

Author(s):

Zahra Abuzaid ◽

Sara Almuslem ◽

Farah Aleisa

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Clinical Outcomes ◽

Recurrent Stroke ◽

Uncontrolled Hypertension ◽

Stroke Recurrence ◽

Stroke Patients ◽

Stroke Event ◽

Uncontrolled Blood Pressure

Background: Hypertension is considered major risk factor for incidence of ischemic stroke, controlling blood pressure reduces this risk, the relationship of uncontrolled blood pressure and stroke outcomes is complex, post stroke uncontrolled blood pressure remains one of the major contributing factors for stroke recurrence and mortality, in our study we studied the long term effects of uncontrolled hypertension in modern health care setting. Methodology: Patients in the study were admitted to the neurology department at KFSH-D between March 2015- August 2019, we included 102 acute ischemic stroke patients whom had hypertension, all patients had follow up appointments at stroke clinic a minimum of 2 visits over 4 years. We retrospectively compared blood pressure data from stroke patients with recurrent ischemic stroke events vs. patients with initial stroke event, and recurrent stroke, also we studied blood pressure readings for different stroke severity groups, patients who had severe stroke with mRS>4, compared to milder stroke group of mRS<4. Results: We found 48 patients identified with recurrent stroke event, those with uncontrolled hypertension had significantly higher stroke recurrence events (P=0.002), despite acute stroke treatment, patients who had history of uncontrolled hypertension were found to have more severe stroke deficits than those who had controlled blood pressure (P=0.029). We found significant difference in the long term stroke clinical outcomes between patients who had uncontrolled blood pressure and patients who had controlled blood pressure recordings within the same hospital setting (P=0.064). Conclusion: Based on our findings, uncontrolled hypertension was associated with higher risk of stroke recurrence, it also increased susceptibility to worse stroke clinical outcomes up to 1 year after initial stroke event, which deserved further close attention and better blood pressure control.

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Abstract 14575: Implantable Cardiac Defibrillator in the Setting of Tetralogy of Fallot: Long-Term Follow-Up of a French National Multicenter Retrospective Registry

Circulation ◽

10.1161/circ.132.suppl_3.14575 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Abdeslam Bouzeman ◽

Maxime De Guillebon ◽

Guillaume Duthoit ◽

Magalie Ladouceur ◽

Raphael Martins ◽

...

Keyword(s):

Risk Factors ◽

Ventricular Tachycardia ◽

Primary Prevention ◽

Secondary Prevention ◽

Tetralogy Of Fallot ◽

Primary And Secondary Prevention ◽

Long Term Follow Up ◽

Appropriate Therapy

Background: Tetralogy of Fallot (TOF) is the most frequent form of congenital heart disease managed by EP physicians for potential ICD. However, few studies have reported long-term outcomes of TOF patients with ICD. Methods: Between 2005 and 2014, all TOF patients with ICD in 17 French centers were enrolled in a specific evaluation aiming to determine characteristics at implantation as well as outcomes (overall mortality, appropriate ICD therapies, and device-related complications). Results: Overall 78 patients (45±13 years, 64% males) were enrolled. A majority of patients were implanted in the setting of secondary prevention (73%), whereas the remaining (27%) in primary prevention. Among the latest group, known risk factors for sudden cardiac death were: severe pulmonary regurgitation (30%,) prior palliative shunt (50%), syncope with unknown origin (25%), inducible ventricular tachycardia (45%), QRS duration ≥180ms (18%), non-sustained ventricular tachycardia (25%), and documented sustained supra ventricular tachycardia (45%).Overall, patients implanted in the setting of primary prevention presented with a mean of 3.1±1.4 risk factors. After a mean follow-up of 4.9±3.8 years, 35 patients (45%) experienced at least one appropriate therapy (25% in the primary prevention group compared to 53% in the secondary prevention group), giving annual-incidences of 6.9% (95%CI 0.14-13.7) and 21.3% (12.4-30.3) respectively (P=0,01). The mean time between ICD implantation and the first appropriate therapy was 2.2±3.2 years, without significant differences between primary and secondary prevention. Overall, ≥one ICD-related complication occurred in 30 patients (38%), including inappropriate shock (n=9), major pocket hematoma (n=1), lead dysfunction (n=12), infection (n=4), shoulder algodystrophia (n=2), device failure or dislodgement needing reintervention (n=2). Eventually, four patients were transplanted (5%), and six patients (8%) died during the course of follow-up. Conclusions: Considering relatively long-term follow-up, patients with TOF and ICDs experience high rates of appropriate ICD therapies, in both primary and secondary prevention. Major ICD-related complications remain, however, high.

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Abstract WP379: Sex-specific Effects of Comorbid Diabetes and Depression on Post-stroke Mortality in Individuals With Atrial Fibrillation

Stroke ◽

10.1161/str.51.suppl_1.wp379 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jodi Edwards ◽

Jessica Colby-Milley ◽

Jiming Fang ◽

Limei Zhou ◽

Baiju R Shah ◽

...

Keyword(s):

Atrial Fibrillation ◽

Hospital Mortality ◽

Recurrent Stroke ◽

Stroke Patients ◽

Comorbid Depression ◽

Term Care ◽

Post Stroke ◽

Specific Effects ◽

Long Term Mortality

Background: Comorbid diabetes and depression are highly prevalent in atrial fibrillation (AF) and increase the risk of stroke. Women with AF show higher mortality rates and have worse functional outcomes post-stroke. However, the sex-specific effects of comorbid diabetes and depression on mortality and other adverse outcomes in stroke patients with a history of AF is unclear. Methods: Prospectively collected consecutive patients with ischemic stroke and known AF presenting to designated stroke centres in Ontario (2003-2013). Multinomial regression was used to determine sex-specific associations between diabetes and depression and in-hospital mortality post-stroke in individuals with AF. Cox proportional hazards regression was used to estimate the adjusted hazard of long-term mortality post-stroke and competing risks models to estimate hazards of recurrent stroke/TIA, admission to long-term care, and incident dementia post-discharge. Results: Among 5082 stroke patients with known AF (median age=80, IQR:73-85), female patients were more likely to have comorbid depression than males (63.5% vs. 36.5%) and those with comorbid diabetes and depression were younger (77 yrs) and had more vascular history (HTN, CAD, hyperlipidemia) than those with AF only. For males, comorbid diabetes increased the likelihood of in-hospital mortality post-stroke by 53% (OR=1.53, 95% CI=1.16-2.02), after adjustment for stroke severity, demographic and clinical factors, while comorbid depression did not significantly impact in-hospital mortality and neither diabetes or depression affected in-hospital mortality post-stroke for females. However, diabetes was independently associated with increased hazard of long-term mortality for both female (HR=1.15, 95%CI=1.02-1.29) and male AF stroke patients (HR=1.35, 95%CI=1.19-1.53). No associations with recurrent stroke/TIA, institutionalization or dementia post-stroke were observed for either females or males. Conclusion: In stroke patients with known AF, comorbid diabetes but not depression was independently associated with increased in-hospital mortality for males and increased long-term mortality post-stroke for both females and males.

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