Abstract W P263: Rapidly Resolving Symptoms..Stop the Race! No Symptoms, No Alteplase!

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Shannon L Smith ◽  
Mark C Schultz
Keyword(s):  
Ischemic Stroke ◽  
Clinical Symptoms ◽  
Research Question ◽  
Heart Association ◽  
Home Health ◽  
Joint Commission ◽  
Poor Outcomes ◽  
Negative Imaging ◽  
The Joint Commission

Background: Research has shown that one-third of patients not treated with thrombolytic therapy due to minor or rapidly improving symptoms have poor outcomes that are considered disabling. The purpose of this study was to determine if opportunities were missed to treat with Alteplase. Research Question: What is the outcome of patients arriving to the emergency room with symptoms of an ischemic stroke not treated with Alteplase because of rapidly improving symptoms? Method: A retrospective analysis of patients between January 2012 and February 2013 with ischemic stroke or TIA, whose ICD-9 coding at discharge is in alignment with the Joint Commission and the American Heart Association. STK 4 from the Joint Commission was used to define the population. Patients with documentation from the physician stating that no Alteplase was given due to rapidly resolving symptoms were included. Magnetic resonance imaging and National Institute of Health scores were used along with clinical symptoms to diagnose potential stroke. Results: Of 47 patients reviewed, 34% had positive imaging and were coded with an ischemic stroke code and 66% had negative imaging and were coded with a transient ischemic attack code. Of the 34% with positive imaging, 38% were discharged to home with home health for therapy follow-up. Of the 66% with negative imaging, 19% were discharged home with home health for therapy follow-up. Of the 47 patients, 6% had a National Institute of Health stroke scale score of 1-3 with positive imaging and 4% had a score of 4 or greater with positive imaging.13% had a score of 0 on admit and 0 on discharge with positive imaging. Conclusion: We found a third of patients who did not receive Alteplase due to rapidly resolving symptoms did have a stroke and several required therapy services after discharge for residual deficits that were potentially disabling. In addition, the National Institute of Health Stroke Scale was not consistently beneficial in diagnosing acute stroke for patients with normal or low scores who were ultimately diagnosed with stroke.

Abstract TP379: “Build It and They Will Come”: How Comprehensive Stroke Certification Increases the Number of Transfers

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Betty Robertson
Keyword(s):  
Research Question ◽  
Heart Association ◽  
Fold Increase ◽  
Joint Commission ◽  
Level Of Care ◽  
Stroke Patients ◽  
Full Spectrum ◽  
Specialized Care ◽  
High Level

Introduction/Background: Stroke is the leading cause of long-term disability affecting 800,000 people in the U.S. each year. In September 2012 The Joint Commission, in collaboration with the American Heart Association/American Stroke Association’s Brain Attack Coalition, launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification recognizes the significant resources in staff and training that comprehensive stroke centers must have to treat complex stroke. Certification is available only to comprehensive stroke centers in Joint Commission-accredited acute care hospitals. For CSC eligibility, there are numerous requirements and volumes that must be met. The most complicated stroke cases should be treated at the centers best equipped to provide specialized care that lead to better outcomes. Cedar-Sinai became the 4 th program in the nation to receive this prestigious certification. By providing expert care, numerous clinical trials, and high level treatment and procedures, we have become the center of choice for patients in need of a higher level of care. Research Question: Does comprehensive stroke certification lead to an increased number of transfers for higher level of care? Methods: Retrospective analysis of the number of acute strokes transferred to Cedars-Sinai between the first years of Comprehensive Stroke Certification in 2012 through 2015. Results: 2012 yielded a total transfer of 97 patients. In 2015 the volume had risen to 194, a 50% increase in 4 years. It is important to note that in 2014, 4 patients were transferred post TPA infusion (Drip and Ship), the gold standard for treatment of ischemic stroke. 2015 resulted in 25 such transfers, a six fold increase. Conclusion: The full spectrum and coordination of services that a CSC is equipped to provide contributes to increased access of specialized care for complex stroke patients. This in turn leads to better outcomes. This not only translates to delivery of timely optimal treatment for stroke patients, but also increases our expertise in delivery of this care.

Improvement in left ventricular mechanics following medical treatment of constrictive pericarditis

Heart ◽  
2021 ◽  
pp. heartjnl-2020-317304
Author(s):  
Kimi Sato ◽  
Ayman Ayache ◽  
Arnav Kumar ◽  
Paul C Cremer ◽  
Brian Griffin ◽  
...  
Keyword(s):  
Constrictive Pericarditis ◽  
Clinical Symptoms ◽  
Heart Association ◽  
Left Ventricular ◽  
Doppler Imaging ◽  
Clinical Resolution ◽  
Ventricular Mechanics ◽  
Anti Inflammatory ◽  
The Impact

ObjectivePatients with constrictive pericarditis (CP) with active inflammation may show resolution with anti-inflammatory therapy. We aimed to investigate the impact of anti-inflammatory medications on constrictive pathophysiology using echocardiography in patients with CP.MethodsWe identified 35 patients with CP who were treated with anti-inflammatory medications (colchicine, prednisone, non-steroidal anti-inflammatory drugs) after diagnosis of CP (mean age 58±13; 80% male). Clinical resolution of CP (transient CP) was defined as improvement in New York Heart Association class during follow-up. We assessed constrictive pathophysiology using regional myocardial mechanics by the ratio of peak early diastolic tissue velocity (e’) at the lateral and septal mitral annulus by tissue Doppler imaging (lateral/septal e’) or the ratio of the left ventricular lateral and septal wall longitudinal strain (LSlateral/LSseptal) by two-dimensional speckle-tracking echocardiography. Longitudinal data were analysed using a mixed effects model.ResultsDuring a median follow-up of 323 days, 20 patients had transient CP, whereas 15 patients had persistent CP. Transient CP had higher baseline erythrocyte sedimentation rates (ESR) (p=0.003) compared with persistent CP. There were no significant differences in LSlateral/LSseptal and lateral/septal e’. During follow-up, only transient CP showed improvement in lateral/septal e’ (p<0.001) and LSlateral/LSseptal (p=0.003), and recovery of inflammatory markers was similar between the two groups. In the logistic model, higher baseline ESR and greater improvement in lateral/septal e’ and LSlateral/LSseptal were associated with clinical resolution of CP using anti-inflammatory therapy.ConclusionsImprovement of constrictive physiology detected by lateral/septal e’ and LSlateral/LSseptal was associated with resolution of clinical symptoms after anti-inflammatory treatment. Serial monitoring of these markers could be used to identify transient CP.

scholarly journals Predictors of poor outcomes in First-Event Ischemic Stroke as assessed by Magnetic Resonance Imaging

2016 ◽  
Vol 39 (3) ◽  
pp. 95 ◽  
Author(s):  
Xiao-Yan Jia ◽  
Ming Huang ◽  
Ya-Fen Zou ◽  
Jiang Wei Tang ◽  
Dan Chen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
High Sensitivity ◽  
Acute Stage ◽  
Stepwise Logistic Regression ◽  
Permanent Disability ◽  
Adequate Treatment ◽  
Increased Risk ◽  
Poor Outcomes

Purpose: Stroke is the third most common cause of mortality worldwide and is a major cause of permanent disability. The purposed of the study was to better understand the risk factors for poor outcomes following ischemic stroke requiring treatment. Methods: Three hundred seventy patients with first-event ischemic stroke were enrolled. Good outcomes was defined as a using the Modified Rankin Scale (MRS) score ≤3 without any cardiovascular event, while poor outcomes were any of the following end points: MRS >3 at 3 months, recurrent stroke or death. Prognostic variables for poor outcomes were analyzed based on a stepwise logistic regression model. Results: Seventy-eight patients had poor outcomes (21%, 78/370), assessed at a minimum of six-month follow-up. Higher mean National Institutes of Health Stroke Scale (NIHSS) scores at presentation, presence of early neurologic deterioration (END) and higher mean high-sensitivity C-reactive protein (hs-CRP) levels were associated with poor outcomes at discharge. Furthermore, both NIHSS at presentation and the presence of END were associated with poor outcomes, assessed at a minimum of six-month follow-up. Conclusion: A higher mean initial NIHSS score implies not only severe neurologic deficits but also an increased risk of poor outcomes. Since END following ischemic stroke is frequently associated with poor outcomes, more attention should be directed to providing adequate treatment to patients in the acute stage, especially for high risk patients.

Abstract TP385: Decreasing Door-to-Needle Times for Acute Ischemic Stroke Patients

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Kelly Venters ◽  
Jessica Douglas ◽  
Amber Parker
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Educational Program ◽  
Regional Hospital ◽  
Joint Commission ◽  
Stroke Patients ◽  
Emergency Department Staff ◽  
Department Staff ◽  
The Joint Commission

Background and Purpose: The Joint Commission recommendation is to meet door-to-needle (DTN) times of less than 60 minutes in 50% of tPA recipients. Lake Cumberland Regional Hospital is a certified primary stroke center by The Joint Commission and has strived to develop a process that drives DTN times to less than 60 minutes for acute ischemic stroke patients being treated with tissue plasminogen activator (tPA). Baseline data from 2014 showed tPA compliance was 27% (n=15). In 2015, pre-implementation tPA compliance was 0% (n=3). Methods: Guided by a process map outlining time frames for all steps in the tPA administration process, findings were utilized to identify barriers, inefficiencies, and solutions. An educational program was developed and centered on identified barriers. Educational sessions were completed for all emergency department staff. DTN times were analyzed before and after implementation of educational program. A timekeeper role was implemented in the emergency department to increase awareness during cases of tPA administration. Results: 100% of Emergency Department staff was educated on process map, Joint Commission recommendations, and role of timekeeper. Since completion of educational sessions and implementation of timekeeper role, Lake Cumberland Regional Hospital has met The Joint Commission DTN recommendation in 78% (n=9) of patients treated with tPA. As of August 11 th , overall DTN compliance for 2015 at Lake Cumberland Regional Hospital was 54%. Conclusions: Average DTN treatment times were decreased and compliance with The Joint Commission standard of meeting DTN times of less than 60 minutes in 50% of tPA cases was improved. For continued identification of performance improvement initiatives, debriefings are conducted after each tPA case with all staff involved to discuss strengths, barriers, and opportunities for improvement.

scholarly journals The Association of Stage 1 Hypertension Defined by the 2017 ACC/AHA Guideline with Stroke and Its Subtypes among Elderly Chinese

2020 ◽  
Vol 2020 ◽  
pp. 1-8 ◽  
Author(s):  
Jinyue Gao ◽  
Yue Dai ◽  
Yanxia Xie ◽  
Jia Zheng ◽  
Yali Wang ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Hemorrhagic Stroke ◽  
American Heart ◽  
Rural China ◽  
Population Attributable Risk ◽  
Heart Association ◽  
Hazard Ratios ◽  
Stage 1

Background. The 2017 American College of Cardiology and American Heart Association hypertension guideline updated stage 1 hypertension definition as systolic blood pressure range from 130 to 139 mmHg or diastolic blood pressure from 80 to 89 mmHg. However, the association of stage 1 hypertension with stroke and its subtypes among the older population in rural China remains unclear. Methods. This population-based cohort study consisted of 7,503 adults aged ≥60 years with complete data and no cardiovascular disease at baseline from rural areas of Fuxin County, Liaoning province, China. Follow-up for the new cases of stroke was conducted from the end of the baseline survey to the end of the third follow-up survey (January 1, 2007–December 31, 2017). Adjusted Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals with the normal blood pressure as a reference, and calculated population attributable risk was based on prevalence and hazard ratios. Results. During a median follow-up of 12.5 years, we observed 1,159 first-ever incident stroke (774 ischemic, 360 hemorrhagic, and 25 uncategorized). With the blood pressure <120/<80 mmHg as a reference, stage 1 hypertension showed the adjusted hazard ratios (95% confidence intervals) of 1.45 (1.11–1.90) for all stroke, 1.65 (1.17–2.33) for ischemic stroke, and 1.17 (0.74–1.85) for hemorrhagic stroke, respectively. In this study, the population attributable risk values of stage 1 hypertension were 10.22% (2.64%–18.56%) for all stroke and 14.34% (4.23%–25.41%) for ischemic stroke. Conclusion. Among adults aged ≥60 years in rural China, stage 1 hypertension defined by 2017 American College of Cardiology and American Heart Association hypertension guideline was independently associated with the increased risk of all stroke and ischemic stroke, excluding hemorrhagic stroke.

scholarly journals Methodological Standards for the Design, Implementation, and Analysis of Randomized Trials in Cardiac Surgery: A Scientific Statement From the American Heart Association

Circulation ◽  
2021 ◽  
Author(s):  
Mario Gaudino ◽  
Joanna Chikwe ◽  
Emilia Bagiella ◽  
Deepak L. Bhatt ◽  
Torsten Doenst ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Trial Design ◽  
Research Question ◽  
Heart Association ◽  
Clinical Equipoise ◽  
Scientific Statement ◽  
Practice Variations ◽  
Study Intervention ◽  
Trial Setting

Cardiac surgery presents specific methodological challenges in the design, implementation, and analysis of randomized controlled trials. The purposes of this scientific statement are to review key standards in cardiac surgery randomized trial design and implementation, and to provide recommendations for conducting and interpreting cardiac surgery trials. Recommendations include a careful evaluation of the suitability of the research question for a clinical trial, assessment of clinical equipoise, feasibility of enrolling a representative patient cohort, impact of practice variations on the safety and efficacy of the study intervention, likelihood and impact of crossover, and duration of follow-up. Trial interventions and study end points should be predefined, and appropriate strategies must be used to ensure adequate deliverability of the trial interventions. Every effort must be made to ensure a high completeness of follow-up; trial design and analytic techniques must be tailored to the specific research question and trial setting.

Abstract TP12: Safety of Antiplatelet Agents within 24 hours of Intra-arterial Thrombolytic Administration in Acute Ischemic Stroke Patients

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Malik M Adil ◽  
Haseeb A Rahman ◽  
Basit Rahim ◽  
Saqib A Chaudhry ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Significant Risk ◽  
Heart Association ◽  
Antiplatelet Agents ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference ◽  
Poor Outcomes ◽  
Prospective Database

Background: Current American Heart Association guidelines recommend withholding all antiplatelet use within 24 hours of thrombolytic use because of concerns regarding an increased risk of intracerebral hemorrhage (ICH). The increased use of emergent thrombectomy, angioplasty, and stent placement in endovascular treatment of acute stroke has prompted a reconsideration of antiplatelet use within 24-hour period. Objective: To determine if there is an increased rate of poor outcomes and ICH in acute ischemic stroke patients that undergo intra-arterial thrombolysis (IAT) and are started on antiplatelets within 24 hours of thrombolytics. Methods: All IAT treated acute ischemic stroke patients identified through a prospective database maintained from two comprehensive stroke centers over a 6-year period. Patients’ clinical characteristics, timing of antiplatelet agents, rates of poor outcome at discharge (modified Rankin score [mRS] of >3) and ICH were obtained and analyzed. Results: Among the total 115 patients that underwent IAT, 65 patients (mean age 60 ± 16.4; 60% men) were started on antiplatelet agents within 24 hours. 43 (66%) patients were started on single antiplatelet, 19 (29%) on dual antiplatelet, and 3 (4.7%) on triple antiplatelet agents within 24 hours of IAT. The proportion of patients with admission NIHSS score>20 was similar in patients who received antiplatelet agents within 24 hours versus those who received them after 24 hours (22% versus 24%, p=0.8) Compared with patients in whom antiplatelets were started after 24 hours, there was no significant difference in the rates of post-procedure ICH (20% versus 9%, p=0.09) and in-hospital mortality (12% versus 12%, p=0.9) in patients started on antiplatelets within 24 hours. There was no significant difference in the rates of poor outcomes (64% versus 71%, p=0.5) between the two groups. Conclusions: Despite the existing recommendation advising against the initiation of antiplatelet agents within 24 hours of thrombolysis, there seems to be no significant risk of increased ICH or mortality with such a practice in IAT cases. Larger prospective studies are needed to identify the benefit of early initiation of antiplatelet agents before broad use is implemented.

scholarly journals Dolichoectatic aneurysms of the vertebrobasilar system: clinical and radiographic factors that predict poor outcomes

2018 ◽  
Vol 128 (2) ◽  
pp. 560-566 ◽  
Author(s):  
David S. Xu ◽  
Michael R. Levitt ◽  
M. Yashar S. Kalani ◽  
Leonardo Rangel-Castilla ◽  
Celene B. Mulholland ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Clinical Symptoms ◽  
Univariate Analysis ◽  
Binary Logistic Regression ◽  
Vertebrobasilar System ◽  
Scale Scores ◽  
Poor Outcomes ◽  
Patient Prognosis ◽  
Vertebrobasilar Aneurysms

OBJECTIVEFusiform dolichoectatic vertebrobasilar aneurysms are rare, challenging lesions. The natural history of these lesions and medium- and long-term patient outcomes are poorly understood. The authors sought to evaluate patient prognosis after diagnosis of fusiform dolichoectatic vertebrobasilar aneurysms and to identify clinical and radiographic predictors of neurological deterioration.METHODSThe authors reviewed multiple, prospectively maintained, single-provider databases at 3 large-volume cerebrovascular centers to obtain data on patients with unruptured, fusiform, basilar artery dolichoectatic aneurysms diagnosed between January 1, 2000, and January 1, 2015.RESULTSA total of 50 patients (33 men, 17 women) were identified; mean clinical follow-up was 50.1 months and mean radiographic follow-up was 32.4 months. At last follow-up, 42% (n = 21) of aneurysms had progressed and 44% (n = 22) of patients had deterioration of their modified Rankin Scale scores. When patients were dichotomized into 2 groups— those who worsened and those who did not—univariate analysis showed 5 variables to be statistically significantly different: sex (p = 0.007), radiographic brainstem compression (p = 0.03), clinical posterior fossa compression (p < 0.001), aneurysmal growth on subsequent imaging (p = 0.001), and surgical therapy (p = 0.006). A binary logistic regression was then created to evaluate these variables. The only variable found to be a statistically significant predictor of clinical worsening was clinical symptoms of posterior fossa compression at presentation (p = 0.01).CONCLUSIONSFusiform dolichoectatic vertebrobasilar aneurysms carry a poor prognosis, with approximately one-half of the patients deteriorating or experiencing progression of their aneurysm within 5 years. Despite being high risk, intervention—when carefully timed (before neurological decline)—may be beneficial in select patients.

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