Abstract 81: Translesional Pressure Gradient Alters the Relationship Between Blood Pressure and Stroke Recurrence in Symptomatic Intracranial Atherosclerotic Disease

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Xueyan Feng ◽  
Ka Lung Chan ◽  
Jill Abrigo ◽  
Linda Lan ◽  
Yannie Soo ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Pressure Gradient ◽  
Stroke Prevention ◽  
Primary Outcome ◽  
Stroke Recurrence ◽  
Secondary Stroke Prevention ◽  
Cfd Models ◽  
Intracranial Atherosclerotic Disease ◽  
The Relationship

Objective: Patients with symptomatic intracranial atherosclerotic stenosis (sICAS) have a high risk of stroke recurrence. There is debate over an optimal blood pressure (BP) lowering target in secondary stroke prevention in such patients, when some factors (e.g., impaired cerebral perfusion) may alter the relationship between BP and risk of stroke recurrence. In this study, we investigated whether translesional pressure gradient across sICAS lesions would also alter such relationship. Methods: We recruited patients with sICAS (50-99% stenosis) confirmed in CT angiography (CTA). Computational fluid dynamics (CFD) models were built based on CTA to simulate blood flow across sICAS and calculate the translesional pressure ratio (PR, the ratio of pressures distal and proximal to a lesion). PR ≤ median was defined as low PR, indicating larger translesional pressure gradient and hence restricted downstream perfusion. The primary outcome was recurrent ischemic stroke in the same territory in 1 year. We investigated the interaction of PR and mean systolic BP (SBP) during follow-up in determining the risk of the primary outcome. Results: Among 157 patients, the median PR was 0.93. Multivariate Cox regression revealed significant PR-SBP interaction on the primary outcome (p=0.025): in patients with normal PR, the risk of primary outcome significantly decreased with lower SBP during follow-up (for 10 mmHg decrement: HR 0.46; p=0.018); however, in those with low PR, mean SBP ≤130 mmHg was associated with significantly increased risk of primary outcome, compared with 130<SBP<150mmHg (HR 5.08; p=0.043) (Figure). Conclusion: Intensive BP lowering may increase the risk of stroke recurrence in sICAS patients with a large translesional pressure gradient, warranting further investigation. PR by CFD models may yield a promising indicator to differentiate sICAS patients for different BP management strategies for better secondary stroke prevention.

scholarly journals Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review

2021 ◽  
Author(s):  
Irum D. Kotadia ◽  
Iain Sim ◽  
Rahul Mukherjee ◽  
Daniel O’Hare ◽  
Amedeo Chiribiri ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Structural Changes ◽  
Stroke Risk ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Stroke Recurrence ◽  
Secondary Stroke Prevention ◽  
Unknown Source ◽  
The Relationship

Abstract Approximately one‐third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one‐third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.

Abstract TP415: Regular Home Blood Pressure Monitoring Reduces the Risk of Stroke Recurrence

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Wenjun Deng ◽  
David McMullin ◽  
Lindsay Fisher ◽  
Richard Chou ◽  
Jared Jacobson ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Blood Pressure Monitoring ◽  
Stroke Recurrence ◽  
Secondary Stroke Prevention ◽  
Stroke Patients ◽  
Self Monitoring ◽  
Recurrent Strokes ◽  
At Home

Background: High blood pressure (BP) is a well recognized risk factor for ischemic stroke, and aggressive BP control is critical for secondary stroke prevention. However, hypertensive (HTN) outpatients are often found to have uncontrolled BP, in part due to poor compliance with daily at-home BP monitoring and consequent poor medication adherence. Here, we explore the association of patient home BP self-monitoring compliance with stroke recurrence. Method: Ischemic stroke patients with pre-existing HTN were prospectively recruited in accordance with IRB protocol for this observational study. All patients were trained on BP self-monitoring as per standard of care, and were asked to monitor BP at home daily consistently for 2 weeks. BP monitoring compliance, per completion of BP log, was assessed at each follow-up clinical visit by an investigator blinded to patient outcome. Stroke recurrence was followed for 5 years and independently adjudicated by two vascular neurologists. Result: In a total of 219 patients, only 36 patients (16.4%) were compliant in completing the home BP log as instructed. The compliant and non-compliant groups showed no baseline difference and no medication usage difference (p>0.05) (Table 1). Compliance with at-home BP monitoring was associated with well controlled systolic (p<0.001) and diastolic BP (p<0.001). Of note, 30 patients (16.4%) had recurrent strokes in the non-compliant group, while there were no recurrent strokes in the compliant group. BP self-monitoring compliance is associated with reduced incidence of stroke recurrence (p=0.030) and the significance remains robust after adjusting for multiple confounders (p=0.029) (Table 2). Conclusion: Regular home BP monitoring is associated with lower risk of stroke recurrence in HTN stroke patients. Study in expanded patient cohort is ongoing to leverage technology for better home BP monitoring and to create incentives for compliant behavior for better secondary stroke prevention.

Abstract 79: Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) Study: Participants, Clinical and Imaging Outcomes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jose G Romano ◽  
Shyam Prabhakaran ◽  
Azhar Nizam ◽  
Edward Feldmann ◽  
Rajbeer Sangha ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Early Recurrence ◽  
Therapeutic Interventions ◽  
Stroke Recurrence ◽  
Multicenter Observational Study ◽  
Intracranial Atherosclerotic Disease ◽  
Study Population ◽  
Study Participants ◽  
Mean Time

Introduction: ICAD is a common cause of stroke. MyRIAD is designed to identify mechanisms of ischemia and predictors of recurrence in ICAD. Here we present the study population baseline characteristics and key outcomes. Methods: MyRIAD is an NIH/NINDS funded prospective multicenter observational study of patients with recent ( < 21 days) stroke or TIA (recurrent or with DWI) caused by IAD 50-99% without planned angioplasty/stenting. The primary outcome is ischemic stroke in the territory within 1 year of follow up; secondary outcomes are TIA at 1 year and new infarcts on MRI at 6-8 weeks. Qualifying events and clinical and imaging outcomes are centrally adjudicated. Results: MyRIAD enrolled 105 participants. The MyRIAD cohort (Table) had significant atherosclerotic risk factors and received aggressive medical therapy. Of 101 participants with clinical follow up (mean 243 + 126 days), the primary outcome of stroke in the territory at 1 year occurred in 9 (8.6%, 13.4/100 person-years), while 7 (6.7%, 10.4/100 person-years) had a TIA. A study MRI at 6-8 weeks was available for comparison to baseline MRI in 87 participants (mean time from qualifying event to follow up imaging 51 + 16 days). A new DWI/FLAIR infarct in the territory of the symptomatic vessel was noted in 22 participants (25.3%). Conclusions: MyRIAD detected an 8.6% 1-year stroke recurrence and a much higher 25.3% rate of recurrent infarction in the first weeks after qualifying stroke/TIA, emphasizing the need to develop better therapeutic interventions for ICAD.

scholarly journals Association between physical exercise and stroke recurrence among first-ever ischemic stroke survivors

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Lisha Hou ◽  
Mier Li ◽  
Ju Wang ◽  
Yawen Li ◽  
Qianwen Zheng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Exercise Duration ◽  
Stroke Recurrence ◽  
Stroke Survivors ◽  
Face To Face ◽  
Baseline Information ◽  
Exercise Type ◽  
The Relationship

AbstractThe relationship between exercise and stroke recurrence is controversial. This study was designed to test whether an association exists between exercise and ischemic stroke recurrence in first-ever ischemic stroke survivors. Data were collected from January 2010 to June 2016. Baseline information was obtained during face-to-face interviews, and follow-up phone interviews were conducted every 3 months. Exercise type, frequency, intensity, and duration were recorded. Discrete-time survival analysis was used to determine the relationship between exercise and stroke recurrence. 760 first-ever ischemic stroke survivors who were able to exercise were enrolled. After adjusting for covariates, patients who exercised 3.5–7 h per week and more than 7 h per week had a lower relapse risk than patients who did not exercise (3.5–7: OR 0.415; > 7: OR 0.356). Moreover, if the fluctuation of exercise duration was over 4 h, the patients had a higher risk of stroke recurrence than those with variability of less than 2 h (OR 2.153, P = 0.013). Stroke survivors who engage in long-term regular mild exercise (more than 5 sessions per week and lasting on average 40 min per session) have a lower recurrence rate. Irregular exercise increases the risk of stroke recurrence.

Abstract WP328: A Nurse-Led Initiative Improves Adherence Rates for Stroke Follow-up and Blood Pressure Management

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Darren T Larsen ◽  
Helmi L Lutsep
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Stroke Prevention ◽  
Stroke Risk ◽  
Retention Rates ◽  
Matched Cohort ◽  
Stroke Patients ◽  
Stroke Risk Factor ◽  
Chi Square Analysis

Background and Issues Aggressive management of vascular risk factors reduces stroke rates. It is unknown whether structured nurse-led follow up increases adherence rates for stroke patients after hospital discharge. Purpose The purpose of this program is to improve secondary stroke risk factor management by instituting a nurse-led initiative called Stroke Therapy, Education, Prevention (STEP). Methods The pilot STEP program was based on protocols used for other stroke prevention trials. This nurse-led program includes inpatient initiation and outpatient maintenance of pharmacologic and lifestyle goals for stroke patients. Eligible patients have a non-disabling ischemic stroke or TIA and are without insurance restrictions and live within a distance allowing return to clinic for follow up. Prior to discharge, the STEP nurse completes patient education, and reviews outpatient goals. The STEP nurse makes phone contact with the patient 7-10 days after discharge to review medication compliance and reinforce education. At 30 days post discharge patients are seen in clinic by the STEP nurse where a resting blood pressure (BP) is measured. If the patient does not meet targets (<140 SBP or <130 SBP for DM) medications are adjusted by a stroke neurologist. We undertook a retrospective chart review of a consecutive cohort of patients matched to STEP eligibility criteria to determine whether the program improved retention rates and BP management. Chi-Square analysis was used to compare visit adherence and percentage achieving goal BPs at 30 days. Results In the STEP group 25/32(78%) patients completed the 30 day follow up compared to 14/32 (44%) patients in the historical matched cohort (p=0.0048). Target BP was achieved in 13/25(52%) STEP patients and 5/14 (36%) matched cohort patients (p=0.32) returning to clinic. Overall, target BP was achieved in 13/32 (41%) and 5/32 (16%) respectively (p=0.026). Conclusions In conclusion, follow up adherence and BP management in the group as a whole was better in the nurse-led model and is recommended for secondary stroke prevention. Long term follow up with this model may further increase in-target rates of BP control and other stroke risk factors.

Abstract 17130: Variables Associated With Uncontrolled Blood Pressure Early After Stroke

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Saviour Achilike ◽  
Austin Wang ◽  
Gabretta Cooksey ◽  
Evelyn Hinojosa ◽  
Munachi Okpala ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Logistic Regression ◽  
Recurrent Stroke ◽  
Stroke Recurrence ◽  
Uncontrolled Blood Pressure ◽  
Factors Associated ◽  
Multivariable Analyses ◽  
Medication Complexity ◽  
Ischemic Attack

Introduction: Uncontrolled blood pressure (BP) is a major risk factor for recurrent stroke; however, up to 50% of stroke survivors have uncontrolled BP 6 months after stroke. Characterization of factors associated with uncontrolled BP early after stroke discharge (DC) may help to identify patients for BP interventions. Hypothesis: We sought to identify factors associated with uncontrolled BP in the first month after stroke discharge. We hypothesized that African American (AA) race, insurance status, medication complexity, and hospital BP prior to discharge would be associated with uncontrolled BP. Methods: We identified hypertensive patients with ischemic or hemorrhagic stroke or transient ischemic attack scheduled to follow-up in the stroke clinic 2 to 4 weeks after hospital DC. Office BP was obtained using BpTRU, an automated machine that averages five unattended BP measures. Uncontrolled BP was defined using 2017 American College of Cardiology Guidelines as BP ≥ 130/80 mmHg. We used univariate logistic regression to assess relationships between uncontrolled BP and selected variables. Variables with statistically significant associations in the univariate models and variables associated with uncontrolled BP in the literature were included in the multiple logistic regression model. Results: Of the 230 patients identified, 55.7% had uncontrolled BP at clinic follow-up. In univariate and multivariable analyses, AA race, young stroke (age < 50), and systolic BP (SBP) 24-hours prior to DC were significantly associated with uncontrolled BP early after stroke DC. BP medication complexity was not associated with uncontrolled BP in this study. Conclusions: AA race, young age, and elevate SBP in the 24 hours prior to of stroke DC were associated with uncontrolled BP early after stroke. These variables can be used to identify patients who may benefit from early interventions aimed at reducing the risk of uncontrolled BP after stroke and stroke recurrence.

Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities

Stroke ◽  
2021 ◽  
Author(s):  
Adam de Havenon ◽  
Kevin N. Sheth ◽  
Tracy E. Madsen ◽  
Karen C. Johnston ◽  
Tanya N. Turan ◽  
...  
Keyword(s):  
Stroke Prevention ◽  
Plasma Lipids ◽  
Gastrointestinal Symptoms ◽  
Cognitive Outcome ◽  
European Medicines Agency ◽  
Stroke Recurrence ◽  
Drug Discontinuation ◽  
Secondary Stroke Prevention ◽  
Long Term Treatment ◽  
Phosphodiesterase Iii Inhibitor

Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol’s pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.

Abstract T P160: Influence of Polyunsaturated Fatty Acids on Cognition in Elderly Alzheimer's Disease Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Takashi Yamazaki ◽  
Ken Nagata ◽  
Daiki Takano ◽  
Tetsuya Maeda
Keyword(s):  
Alzheimer’S Disease ◽  
Blood Pressure ◽  
Alzheimer's Disease ◽  
Cognitive Function ◽  
Mmse Score ◽  
Characteristic Curve ◽  
Follow Up Study ◽  
Cognitive Stability ◽  
The Relationship

Background: Many genes and environmental factors linked to Alzheimer’s disease (AD) risk affect lipid metabolism or the cardiovascular system, strongly implicating cerebrovascular and metabolic dysfunction in AD pathogenesis. Although some PUFAs may improve cognitive function in aging individuals, it is still unclear how different PUFAs influence AD neuropathology and cognitive function. Objective: To examine the influence of polyunsaturated fatty acid (PUFA) metabolism on AD-associated cognitive decline, we investigated the relationship between serum PUFA profile and neuropsychological test performance. Methods: Cognitive functioning in patients with probable AD (n = 174, mean age 77.6 years) was examined using the Mini-Mental State Exam (MMSE) and clock drawing test (CDT). Serum samples were obtained for PUFA profile, including the eicosapentaenoic acid/arachidonic acid (EPA/AA) ratio, and measurement of brain natriuretic peptide (BNP) concentration. In the follow-up study, 47 subjects repeated MMSE and CDT after 1 year, According to the second MMSE score, the subjects were divided into the following 2 groups: those with unchanged or improved MMSE score and those with lower MMSE score. A receiver operating characteristic curve was used to evaluate the relationship between the EPA/AA ratio and 1-year cognitive stability. Results: In the cross-sectional study, total MMSE score correlated positively with the EPA/AA ratio and systolic blood pressure (SBP), and negatively with age and diastolic blood pressure (DBP) (p < 0.05). In the follow-up study, the MMSE score was lower than baseline in 20 subjects, whereas it was improved or unchanged in 29 patients. The EPA/AA ratio in the stable group was significantly greater than that in the deteriorating group, suggesting an association between higher EPA/AA ratio and cognitive stability over 1 year. The EPA/AA ratio predicted stability of cognitive performance with a sensitivity of 66% and specificity of 70% (odds ratio = 4.43) when the cut-off was 0.67. Conclusion: Our results suggest that serum EPA concentration strongly influences cognitive performances in AD patients. The EPA/AA ratio was a sensitive indicator of cognitive stability in this patient group.

scholarly journals Diabetic Retinopathy and Risk of Stroke

Stroke ◽  
2020 ◽  
Vol 51 (12) ◽  
pp. 3733-3736
Author(s):  
Ka-Ho Wong ◽  
Katherine Hu ◽  
Cecilia Peterson ◽  
Nazanin Sheibani ◽  
Georgios Tsivgoulis ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Diabetic Retinopathy ◽  
Primary Outcome ◽  
Vision Loss ◽  
Proportional Hazards ◽  
Cox Regression ◽  
Secondary Analysis ◽  
Cox Proportional Hazards ◽  
Increased Risk

Background and Purpose: Diabetic retinopathy (DR) is a common microvascular complication of diabetes, which causes damage to the retina and may lead to rapid vision loss. Previous research has shown that the macrovascular complications of diabetes, including stroke, are often comorbid with DR. We sought to explore the association between DR and subsequent stroke events. Methods: This is a secondary analysis of patients enrolled in the ACCORD Eye study (Action to Control Cardiovascular Risk in Diabetes). The primary outcome was stroke during follow-up. The exposure was presence of DR at study baseline. We fit adjusted Cox proportional hazards models to provide hazard ratios for stroke and included interaction terms with the ACCORD randomization arms. Results: We included 2828 patients, in whom the primary outcome of stroke was met by 117 (4.1%) patients during a mean (SD) of 5.4 (1.8) years of follow-up. DR was present in 874 of 2828 (30.9%) patients at baseline and was more common in patients with than without incident stroke (41.0% versus 30.5%; P =0.016). In an adjusted Cox regression model, DR was independently associated with incident stroke (hazard ratio, 1.52 [95% CI, 1.05–2.20]; P =0.026). This association was not affected by randomization arm in the ACCORD glucose ( P =0.300), lipid ( P =0.660), or blood pressure interventions ( P =0.469). Conclusions: DR is associated with an increased risk of stroke, which suggests that the microvascular pathology inherent to DR has larger cerebrovascular implications. This association appears not to be mediated by serum glucose, lipid, and blood pressure interventions.

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