External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients

Introduction: Prior stroke is a risk factor for stroke and bleeding during anticoagulation in patients with atrial fibrillation (AF). Although rivaroxaban is widely prescribed to reduce their risk of stroke in patients with nonvalvular AF (NVAF), the real-world evidence on rivaroxaban treatment is limited. We aimed to examine the outcomes of rivaroxaban treatment in NVAF patients with prior ischemic stroke/transient ischemic attack (TIA) by using the data of the Xarelto Post-Authorization Safety and Effectiveness Study in Japanese Patients with AF, a prospective, single-arm, observational study. Methods: The clinical outcomes of 9,578 patients who completed the 1-year follow-up were evaluated. Safety and effectiveness outcomes were compared between patients with and without prior ischemic stroke/TIA. Results: Among the patients, 2,153 (22.5%) had prior ischemic stroke/TIA. They were significantly older and had lower body weight, lower creatinine clearance, higher CHADS2, CHA2DS2-VASc, and modified HAS-BLED scores as compared to those without prior ischemic stroke/TIA. Any bleeding (9.1 vs. 7.2 events per 100 patient-years), major bleeding (2.3 vs. 1.6 events per 100 patient-years), and stroke/non-central nervous system systemic embolism/myocardial infarction (3.4 vs. 1.3 events per 100 patient-years) were more frequent in patients with prior ischemic stroke/TIA. Stepwise regression analysis suggested that body weight of ≤50 kg and diabetes mellitus were predictive of major bleeding in patients with prior ischemic stroke/TIA. Conclusions: Safety and effectiveness event rates were higher in patients with prior ischemic stroke/TIA than those without. This might be explained by differences in several risk profiles including age, body weight, renal function, and risk scores such as CHADS2 between the groups. Clinicaltrials.gov: NCT01582737.

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Clinical Effects of Dual Antiplatelet Therapy or Aspirin Monotherapy after Acute Minor Ischemic Stroke or Transient Ischemic Attack, a Meta-Analysis

Current Pharmaceutical Design ◽

10.2174/1381612827666210728102459 ◽

2021 ◽

Vol 27 ◽

Author(s):

Francesco Condello ◽

Gaetano Liccardo ◽

Giuseppe Ferrante

Keyword(s):

Ischemic Stroke ◽

Major Bleeding ◽

Transient Ischemic Attack ◽

Hemorrhagic Stroke ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Stroke Recurrence ◽

Controlled Trials ◽

Minor Ischemic Stroke ◽

Ischemic Attack

Background: Evidence about the use of dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with acute minor ischemic stroke or transient ischemic attack (TIA) is emerging. The aim of our study was to provide an updated and comprehensive analysis about the risks and benefits of DAPT versus aspirin monotherapy in this setting. Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov databases, main international conference proceedings were searched for randomized controlled trials comparing DAPT versus aspirin monotherapy in patients with acute ischemic stroke or TIA not eligible for thrombolysis or thrombectomy presenting in the first 24 hours after the acute event. Data were pooled by meta-analysis using a random-effects model. The primary efficacy endpoint was ischemic stroke recurrence, and the primary safety outcome was major bleeding. Secondary endpoints were intracranial hemorrhage, hemorrhagic stroke, and all-cause death. Results: A total of 4 studies enrolling 21,459 patients were included. DAPT with clopidogrel was used in 3 studies, DAPT with ticagrelor in one study. DAPT duration was 21 days in one study, 1 month in one study, and 3 months in the remaining studies. DAPT was associated with a significant reduction in the risk of ischemic stroke recurrence (relative risk [RR], 0.74; 95% confidence interval [CI], 0.67-0.82, P<0.001, number needed to treat 50 [95% CI 40-72], while it was associated with a significantly higher risk of major bleeding (RR, 2.59; 95% CI 1.49-4.53, P=0.001, number needed to harm 330 [95% CI 149-1111]), of intracranial hemorrhage (RR 3.06, 95% CI 1.41-6.66, P=0.005), with a trend towards higher risk of hemorrhagic stroke (RR 1.83, 95% CI 0.83-4.05, P=0.14), and a slight tendency towards higher risk of all-cause death (RR 1.30, 95% CI 0.89-1.89, P=0.16). Conclusions: Among patients with acute minor ischemic stroke or TIA, DAPT, as compared with aspirin monotherapy, might offer better effectiveness in terms of ischemic stroke recurrence at the expense of a higher risk of major bleeding. The trade-off between ischemic benefits and bleeding risks should be assessed in tailoring the therapeutic strategies.

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Associations between Pre-Admission Risk Scores and Two-Year Clinical Outcomes in Ischemic Stroke or Transient Ischemic Attack Patients with Non-Valvular Atrial Fibrillation

Cerebrovascular Diseases ◽

10.1159/000487896 ◽

2018 ◽

Vol 45 (3-4) ◽

pp. 170-179 ◽

Cited By ~ 1

Author(s):

Keisuke Tokunaga ◽

Hiroshi Yamagami ◽

Masatoshi Koga ◽

Kenichi Todo ◽

Kazumi Kimura ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Clinical Outcomes ◽

Scale Score ◽

Outcome Measures ◽

Transient Ischemic Attack ◽

Risk Scores ◽

Modified Rankin Scale ◽

Hemorrhagic Events ◽

Ischemic Attack

Background: We aimed to clarify associations between pre-admission risk scores (CHADS2, CHA2DS2-VASc, and HAS-BLED) and 2-year clinical outcomes in ischemic stroke or transient ischemic attack (TIA) patients with non-valvular atrial fibrillation (NVAF) using a prospective, multicenter, observational registry. Methods: From 18 Japanese stroke centers, ischemic stroke or TIA patients with NVAF hospitalized within 7 days after onset were enrolled. Outcome measures were defined as death/disability (modified Rankin Scale score ≥3) at 2 years, 2-year mortality, and ischemic or hemorrhagic events within 2 years. Results: A total of 1,192 patients with NVAF (527 women; mean age, 78 ± 10 years), including 1,141 ischemic stroke and 51 TIA, were analyzed. Rates of death/disability, mortality, and ischemic or hemorrhagic events increased significantly with increasing pre-admission CHADS2 (p for trend <0.001 for death/disability and mortality, p for trend = 0.024 for events), CHA2DS2-VASc (p for trend <0.001 for all), and HAS-BLED (p for trend = 0.004 for death/disability, p for trend <0.001 for mortality, p for trend = 0.024 for events) scores. Pre-admission CHADS2 (OR per 1 point, 1.52; 95% CI 1.35–1.71; p <0.001 for death/disability; hazard ratio (HR) per 1 point, 1.23; 95% CI 1.12–1.35; p <0.001 for mortality; HR per 1 point, 1.14; 95% CI 1.02–1.26; p = 0.016 for events), CHA2DS2-VASc (1.55, 1.41–1.72, p < 0.001; 1.21, 1.12–1.30, p < 0.001; 1.17, 1.07–1.27, p < 0.001; respectively), and HAS-BLED (1.33, 1.17–1.52, p < 0.001; 1.23, 1.10–1.38, p < 0.001; 1.18, 1.05–1.34, p = 0.008; respectively) scores were independently associated with all outcome measures. Conclusions: In ischemic stroke or TIA patients with NVAF, all pre-admission risk scores were independently associated with death/disability at 2 years and 2-year mortality, as well as ischemic or hemorrhagic events within 2 years.

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Population-Based Case–Control Study of White Matter Changes on Brain Imaging in Transient Ischemic Attack and Ischemic Stroke

Stroke ◽

10.1161/strokeaha.113.002775 ◽

2013 ◽

Vol 44 (11) ◽

pp. 3063-3070 ◽

Cited By ~ 20

Author(s):

Linxin Li ◽

Michela Simoni ◽

Wilhelm Küker ◽

Ursula G. Schulz ◽

Sharon Christie ◽

...

Keyword(s):

Ischemic Stroke ◽

White Matter ◽

Brain Imaging ◽

Transient Ischemic Attack ◽

Case Control Study ◽

Population Based ◽

Case Control ◽

White Matter Changes ◽

Ischemic Attack ◽

Control Study

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Transient ischemic attack and ischemic stroke patients with or without prior stroke

Acta Neurologica Scandinavica ◽

10.1111/ane.12782 ◽

2017 ◽

Vol 136 (6) ◽

pp. 654-659 ◽

Cited By ~ 2

Author(s):

F. Buchwald ◽

B. Norrving ◽

J. Petersson

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Stroke Patients ◽

Ischemic Attack ◽

Prior Stroke

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Coronary Artery Disease in Patients Presenting With Acute Ischemic Stroke or Transient Ischemic Attack and Elevated Troponin Levels

Frontiers in Neurology ◽

10.3389/fneur.2021.781553 ◽

2022 ◽

Vol 12 ◽

Author(s):

Mathieu Kruska ◽

Anna Kolb ◽

Christian Fastner ◽

Iris Mildenberger ◽

Svetlana Hetjens ◽

...

Keyword(s):

Coronary Artery Disease ◽

Ischemic Stroke ◽

Cardiovascular Risk ◽

Coronary Artery ◽

Transient Ischemic Attack ◽

Large Artery ◽

Elevated Troponin ◽

Stroke Patients ◽

Artery Disease ◽

Ischemic Attack

Background: There is little information concerning the invasive coronary angiography (ICA) findings of patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) with elevated troponin levels and suspected myocardial infarction (MI). This study analyzed patient characteristics associated with ICA outcomes.Methods: A total of 8,322 patients with AIS or TIA, treated between March 2010 and May 2020, were retrospectively screened for elevated serum troponin I at hospital admission. Patients in whom ICA was performed, due to suspected type 1 MI based on symptoms, echocardiography, and ECG, were categorized according to ICA results (non-obstructive coronary artery disease (CAD): ≥1 stenosis ≥50% but no stenosis ≥80%; obstructive CAD: any stenosis ≥80% or hemodynamically relevant stenosis assessed by FFR/iwFR).Results: Elevated troponin levels were detected in 2,205 (22.5%) patients, of whom 123 (5.6%) underwent ICA (mean age 71 ± 12 years; 67% male). CAD was present in 98 (80%) patients, of whom 51 (41%) were diagnosed with obstructive CAD. Thus, ICA findings of obstructive CAD accounted for 2.3% of patients with troponin elevation and 0.6% of all stroke patients. The clinical hallmarks of myocardial ischemia, including angina pectoris (31 vs. 15%, p < 0.05) and regional wall motion abnormalities (49 vs. 32%, p = 0.07), and increased cardiovascular risk indicated obstructive CAD. While there was no association between lesion site or stroke severity and ICA findings, causal large-artery atherosclerosis was significantly more common in patients with obstructive coronary disease (p < 0.05).Conclusion: The rate of obstructive CAD in patients with stroke or TIA and elevated troponin levels with suspected concomitant type I MI is low. The cumulation of several cardiovascular risk factors and clinical signs of MI were predictive. AIS patients with large-artery atherosclerosis and elevated troponin may represent an especially vulnerable subgroup of stroke patients with risk for obstructive CAD.

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Comparison of Carotid Atherosclerotic Plaque Characteristics between Symptomatic Patients with Transient Ischemic Attack and Stroke using High-Resolution Magnetic Resonance Imaging

10.21203/rs.3.rs-1089154/v1 ◽

2021 ◽

Author(s):

Mingming Lu ◽

Lichen Zhang ◽

Fei Yuan ◽

Peng Peng ◽

Hongtao Zhang ◽

...

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Transient Ischemic Attack ◽

Carotid Arteries ◽

Plaque Burden ◽

Plaque Morphology ◽

Stroke Patients ◽

Carotid Plaques ◽

Ischemic Attack ◽

Ischemic Events

Abstract Background:This study aimed to compare the characteristics of carotid plaques between patients with transient ischemic attack (TIA) and ischemic stroke using magnetic resonance (MR) imaging.Methods：Patients with a recent ischemic stroke or TIA who exhibited atherosclerotic plaques of carotid arteries in the symptomatic sides determined by MR vessel wall imaging were recruited. The plaque morphology and compositions including intraplaque hemorrhage (IPH), lipid-rich necrotic-core (LRNC) and calcification were compared between TIA and stroke patients. Logistic regression was performed to relate the plaque characteristics to the types of ischemic events.Results:A total of 270 patients with TIA or ischemic stroke were recruited. Stroke patients had significantly higher prevalence of diabetes (42.2% vs. 28.2%, p=0.021), greater mean wall area (35.1 ± 10.1 mm2 vs. 32.0 ± 7.7 mm2, p = 0.004), mean wall thickness (1.3 ± 0.2 mm vs. 1.2 ± 0.2 mm, p=0.001), maximum normalized wall index (NWI)(63.9% ± 6.0% vs. 62.2% ± 5.9%, p=0.023) and %volume of LRNC (9.7%± 8.2% vs. 7.4% ±7.9%, p=0.025) in carotid arteries compared to those with TIA. After adjusted for clinical factors, above characteristics of carotid arteries were significantly associated with the type of ischemic events. After further adjusted for maximum NWI, this association remained statistically significant (OR, 1.41; CI, 1.01-1.96; p=0.041).Conclusions:Ischemic stroke patients had larger plaque burden and greater proportion of LRNC in carotid plaques compared to those with TIA. This study suggests that ischemic stroke patients had more vulnerable plaques compared to those with TIA.

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Acute stroke and TIA patients have specific polygraphic features of obstructive sleep apnea

Sleep And Breathing ◽

10.1007/s11325-019-02010-2 ◽

2020 ◽

Vol 24 (4) ◽

pp. 1495-1505 ◽

Cited By ~ 2

Author(s):

Akseli Leino ◽

Susanna Westeren-Punnonen ◽

Juha Töyräs ◽

Sami Myllymaa ◽

Timo Leppänen ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Ischemic Stroke ◽

Sleep Apnea ◽

Transient Ischemic Attack ◽

Sleep Disordered Breathing ◽

Apnea Hypopnea Index ◽

Stroke Patients ◽

Respiratory Events ◽

Obstructive Sleep ◽

Ischemic Attack

Abstract Purpose Obstructive sleep apnea (OSA) is associated with increased risk for stroke, which is known to further impair respiratory functions. However, it is unknown whether the type and severity of respiratory events are linked to stroke or transient ischemic attack (TIA). Thus, we investigate whether the characteristics of individual respiratory events differ between patients experiencing TIA or acute ischemic stroke and matched patients with clinically suspected sleep-disordered breathing. Methods Polygraphic data of 77 in-patients with acute ischemic stroke (n = 49) or TIA (n = 28) were compared to age, gender, and BMI-matched patients with suspected sleep-disordered breathing and no cerebrovascular disease. Along with conventional diagnostic parameters (e.g., apnea-hypopnea index), durations and severities of individual apneas, hypopneas and desaturations were compared between the groups separately for ischemic stroke and TIA patients. Results Stroke and TIA patients had significantly shorter apneas and hypopneas (p < 0.001) compared to matched reference patients. Furthermore, stroke patients had more central apnea events (p = 0.007) and a trend for higher apnea/hypopnea number ratios (p = 0.091). The prevalence of OSA (apnea-hypopnea index ≥ 5) was 90% in acute stroke patients and 79% in transient ischemic attack patients. Conclusion Stroke patients had different characteristics of respiratory events, i.e., their polygraphic phenotype of OSA differs compared to matched reference patients. The observed differences in polygraphic features might indicate that stroke and TIA patients suffer from OSA phenotype recently associated with increased cardiovascular mortality. Therefore, optimal diagnostics and treatment require routine OSA screening in patients with acute cerebrovascular disease, even without previous suspicion of OSA.

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Renal dysfunction and chronic kidney disease in ischemic stroke and transient ischemic attack: A population-based study

International Journal of Stroke ◽

10.1177/1747493017701148 ◽

2017 ◽

Vol 12 (7) ◽

pp. 761-769 ◽

Cited By ~ 9

Author(s):

Derek Hayden ◽

Christine McCarthy ◽

Layan Akijian ◽

Elizabeth Callaly ◽

Danielle Ní Chróinín ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Ischemic Stroke ◽

Kidney Disease ◽

Renal Dysfunction ◽

Transient Ischemic Attack ◽

Population Based ◽

Population Based Study ◽

Ischemic Attack

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Prevalence of Thrombophilia in Transient Ischemic Attack and Ischemic Stroke Patients

Blood ◽

10.1182/blood-2020-133476 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 3-3

Author(s):

Omar Raslan ◽

Christopher Tran ◽

Fatimah Al-Ani ◽

Luciano Sposato ◽

Alejandro Lazo-Langner

Keyword(s):

Ischemic Stroke ◽

High Risk ◽

Transient Ischemic Attack ◽

Patent Foramen Ovale ◽

Research Funding ◽

Transient Ischemic Attacks ◽

Foramen Ovale ◽

Stroke Patients ◽

Thrombophilia Screening ◽

Ischemic Attack

Introduction. Screening for inherited thrombophilia has been recommended in patients with cryptogenic ischemic strokes and anticoagulant therapy is frequently indicated based on these results. However, current evidence suggests that thrombophilia screening is over utilized in stroke patients and may provide more risks than benefits. Patients and Methods.We conducted a retrospective cohort study in patients with transient ischemic attack (TIA) or ischemic stroke who had a thrombophilia screen and determined the proportions of each thrombophilia trait, and the proportion of high risk thrombophilia in this population. Pre-specified subgroup analyses were conducted for patients with ischemic stroke and transient ischemic attacks, and for patients with patent foramen ovale. Results.We included 412 patients (152 male and 260 female). The prevalence of thrombophilia was 7.52% (95% CI 5.35-10.48). The proportion of major thrombophilia was 2.18 (95% CI=1.15 - 4.09). The proportion of thrombophilia traits in ischemic stroke patients was lower 4.92% (95% CI 2.61 - 9.08) than that in patients with transient ischemic attacks 9.57% (95% CI = 6.41 - 14.06); Only 2 individuals had both a positive thrombophilia screen and a patent foramen ovale. Discussion. In this study the prevalence of thrombophilia traits in patients with ischemic stroke or transient ischemic attack was low, including high risk thrombophilic traits. Further studies are needed to determine if thrombophilia screening exposes these patients to additional risks without any benefits. Disclosures Sposato: Western University:Other: Kathleen and Dr. Henry Barnett Chair in Stroke Research;Boehringer Ingelheim:Honoraria, Research Funding;Pfizer:Honoraria, Research Funding;Gore:Honoraria, Research Funding;Bayer:Honoraria, Research Funding.

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