scholarly journals Anticoagulants as more effective secondary prevention for embolic stroke of undetermined source: retrospective cohort study

2018 ◽  
Author(s):  
Yuya Sakakura ◽  
Yoichiro Homma ◽  
Tomoya Arakawa ◽  
Tokutaro Tanaka
Keyword(s):  
Ischemic Stroke ◽  
Likelihood Ratio ◽  
Stroke Prevention ◽  
Small Sample Size ◽  
Small Sample ◽  
Embolic Stroke ◽  
Rank Test ◽  
Ratio Test ◽  
Secondary Stroke Prevention ◽  
Stroke Center

Abstract Background: Whether anticoagulants or antiplatelets are more effective for secondary stroke prevention for embolic stroke of undetermined source (ESUS) remains unknown. These two treatments were compared retrospectively. Methods: Of 779 acute ischemic stroke inpatients between January 2012 and December 2014 in our stroke center, 110 patients met our ESUS criteria were compared. Antiplatelets were used in 81 patients, and anticoagulants were used in 29. ESUS criteria by Hart et al., except for extracranial atherosclerosis, were used. In all patients, intracranial magnetic resonance angiograms were obtained, and the infarct was diagnosed with positive diffusion studies. The primary outcome was recurrence-free survival. Score-tests for the hazard ratio assumption and for covariate effects in the Cox proportional hazard model were performed. To estimate hazard ratios, a likelihood ratio test and the Kaplan-Meier method and log-rank test were used. This study protocol was approved by the Institutional Review Board of the hospital. Results: The mean follow-up period was 84.0±65.5 weeks, and 14 patients treated with antiplatelets and one treated with anticoagulants developed recurrent ischemic stroke. The antiplatelet group had a significantly higher risk of recurrence than the anticoagulant group (p=0.0293, likelihood ratio 0.144, 95% confidence interval [CI]: 0.019-1.096). Multivariate analysis also showed a similar result (p=0.013, likelihood ratio -1.94, 95% CI: 0.01-0.72, respectively). Conclusions: These findings suggest that anticoagulants are more effective than antiplatelets for secondary stroke prevention for ESUS patients, although this was a non-randomized, single-center, retrospective analysis with a small sample size. Further studies are needed to accumulate enough evidence.

Abstract 2559: Subgroup analysis of the Cilostazol Stroke Prevention Study 2 (CSPS 2)

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Shinichiro Uchiyama ◽  
Keyword(s):  
Ischemic Stroke ◽  
Subgroup Analysis ◽  
Stroke Prevention ◽  
Significant Interaction ◽  
Japanese Patients ◽  
Rank Test ◽  
Secondary Stroke Prevention ◽  
Lacunar Stroke ◽  
Significant Difference ◽  
Aspirin Group

Background: Cilostazol has been suggested to be superior to aspirin in secondary stroke prevention in patients with non-cardioembolic ischemic stroke from the results of the CSPS 2 and meta-analysis of the Cochrane Collaboration. The purpose of this study was to investigate the efficacy and safety of cilostazol and aspirin in the various subgroups of the study population. Methods: Recurrence of stroke was studied in the subgroup analysis according to patient's characteristics, concomitant use of drugs, and ischemic stroke subtypes. Heterogeneity of stroke risk between subgroups classified by each variable was analyzed using Log-rank test. Results: A total of 2672 Japanese patients enrolled in the CSPS 2 (Lancet Neurol 2010;9:959-68) were analyzed. A tendency of interaction was observed in alcohol drinking (p=0.0782) and dyslipidemia (p=0.0873). Stroke rates in alcohol drinkers (HR 0.574, 95% CI 0.386-0.855) and non-dyslipidemic patients (HR 0.608, 95% CI 0.426-0.869) were lower in the cilostazol group than in the aspirin group. A significant interaction was demonstrated in the use of angiotensin receptor blocker (ARB) (p=0.0267). Stroke rate in non-users of ARB was lower in the cilostazol group than in the aspirin group (HR 0.542, 95% CI 0.370-0.793), while it was not different between both groups in users of ARB (HR 1.016, 95% CI 0.677-1.524). There was no significant difference in the rate of ischemic stroke between both treatment groups in patients with atherothrombotic stroke (cilostazol 1.77%/year, aspirin 2.45%/year, p=0.2808) and lacunar stroke (cilostazol 2.68%, aspirin 2.88%/year, p=0.7198). The rate of hemorrhagic stroke was not different between both groupsin patients with atherothrombotic stroke (cilostazol 0.31%/year, aspirin 0.59%/year, p=0.3444), while it was significantly much lower in the cilostazol group (0.36%/year) than in the aspirin group (1.20%/year) (RRR 65.0%, p=0.0030) among patients with lacunar stroke. Conclusion: Superiority of cilostazol over aspirin in secondary stroke prevention tended to be more obvious in alcohol drinkers and non-dyslipidemics. A significant interaction was observed in the concomitant use of ARB, which might be related to pleiotropic effects of cilostazol and ARB. Cilostazol has an advantage over aspirin in lower risk of cerebral hemorrhage especially in Japanese patients with lacunar stroke.

Abstract W P224: Higher Pre-Hospital Blood Pressure Prolongs Door to Needle Thrombolysis Times

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Digvijaya Navalkele ◽  
Chunyan Cai ◽  
Mohammad Rahbar ◽  
Renganayaki Pandurengan ◽  
Tzu-Ching Wu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Small Sample Size ◽  
Heart Association ◽  
Small Sample ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Intravenous Tissue Plasminogen Activator ◽  
Number Of Patients

Background: Per American Heart Association guidelines, blood pressure (BP) should be < 185/110 to be eligible for intravenous tissue plasminogen activator (tPA). It is shown that door to needle (DTN) time is prolonged in patients who require anti-hypertensive medications prior to thrombolysis in the emergency department (ED). To our knowledge, no studies have focused on pre-hospital BP and its impact on DTN times. We hypothesize that DTN times are longer for patients with higher pre-hospital BP. Methods: We conducted a retrospective review of acute ischemic stroke patients who presented between 1/2010 and 12/2010 to our ED through Emergency Medical Services (EMS) within 3-hrs of symptom onset. Patients were identified from our registry and categorized into two groups: Pre-hospital BP ≥ 185/110 (Pre-hsp HBP) and < 185/110 (Pre-hsp LBP). BP records were abstracted from EMS sheets. Two groups were compared using two-sample t-test or Wilcoxon rank sum test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. Results: A total of 107 consecutive patients were identified. Out of these, 75 patients (70%) were treated with tPA. Among the patients who received thrombolysis, 35% had pre-hospital BP ≥ 185/110 (n= 26/75). Greater number of patients required anti-hypertensive medications in ED in high BP group compared to low BP group (Pre-hsp HBP n= 14/26, 54%; Pre-hsp LBP n= 13/49, 27%, p < 0.02). Mean door to needle times were significantly higher in Pre-hsp HBP group. (mean ± SD 87.5± 34.2 Vs. 59.7±18.3, p<0.0001). Analysis of patients only within the Pre-hsp HBP group (n= 26) revealed that DTN times were shorter if patients received pre-hsp BP medications compared to patients in the same group who did not receive pre-hsp BP medication (n= 10 vs 16; mean ± SD 76.5 ± 25.7 Vs. 94.3 ± 37.7, p = 0.20) Conclusion: Higher pre-hospital BP is associated with prolonged DTN times and it stays prolonged if pre-hospital high BP remains untreated. Although the later finding was not statistical significant due to small sample size, pre-hospital blood pressure control could be a potential area for improvement to reduce door to needle times in acute ischemic stroke.

Abstract P252: Discharge Antithrombotic Therapy for Ischemic Stroke Patients With Prior Aspirin Failure

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ying Xian ◽  
Haolin Xu ◽  
Deepak L Bhatt ◽  
Gregg C Fonarow ◽  
Eric E Smith ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Antithrombotic Therapy ◽  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
The United States ◽  
Future Research ◽  
Large Artery ◽  
Secondary Stroke Prevention ◽  
Stroke Registry

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients. Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017. Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge. Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

scholarly journals Resource selection by Javan Slow Loris Nycticebus javanicus E. Geoffroy, 1812 (Mammalia: Primates: Lorisidae) in a lowland fragmented forest in Central Java, Indonesia

2019 ◽  
Vol 11 (6) ◽  
pp. 13667-13679 ◽  
Author(s):  
Mahfut Sodik ◽  
Satyawan Pudyatmoko ◽  
Pujo Semedi Hargo Yuwono ◽  
Muhammad Ali Imron
Keyword(s):  
Resource Selection ◽  
Small Sample Size ◽  
Canopy Cover ◽  
Small Sample ◽  
Habitat Characteristics ◽  
Ratio Test ◽  
Natural Habitats ◽  
Slow Loris ◽  
Central Java ◽  
Habitat Variables

Habitat loss and forest fragmentation have negative impacts on Javan Slow Loris Nycticebus javanicus, a Critically Endangered nocturnal primate endemic to Java.  Reports confirmed that less than 9% of forest area remains on Java Island.  One of the remaining natural habitats of the Javan Slow Loris is the fragment of Kemuning Forest in Temanggung Regency, Central Java.  The purpose of this study was to determine resource selection and habitat variables that determine the presence of Javan Slow Loris.  Habitat variables measured were basal area, tree connectivity, crown coverage on tree stage, slope, elevation, and distance to river.  Data analysis performed was logistic regression, likelihood ratio test, and Akaike’s Information Criterion with a backward elimination procedure.  We also used direct observation and interviews with locals to collect data on environment and anthropogenic features of this forest.  The results showed that the Javan Slow Loris uses resources selectively on a microhabitat scale.  The habitat factors that influence the probability of resource selection by the species are canopy cover and slope.  Habitat characteristics preferred by the Javan Slow Loris in Kemuning Forest are secondary lowland tropical rainforest with dense canopy cover located on a steep slope with low level of habitat disturbances.  Although this study uses a small sample size, the expectation is that the results can be used as preliminary information for the habitat and population management of Javan Slow Loris in Kemuning Forest to guide conservation efforts and design management strategies.

Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ying Xian ◽  
Peter Shrader ◽  
Eric Smith ◽  
Gregg C Fonarow ◽  
Deepak L Bhatt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Patient Characteristics ◽  
Minor Stroke ◽  
Secondary Stroke Prevention ◽  
Class Iii ◽  
Prescription Patterns ◽  
Class Iib ◽  
Over Time

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit >> risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p<0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p<0.001) and those with NIHSS>3 (18.7%, 22.8%, 28.3%, and 28.3%, p<0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS>3, where the risk-benefit ratio of DAPT remains to be established.

Abstract WP277: The Los Angeles Motor Scale is an Effective Tool for Triaging Patients in the Prehospital Setting

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Tej Stead ◽  
Latha Ganti ◽  
Paul Banerjee
Keyword(s):  
Los Angeles ◽  
Likelihood Ratio ◽  
Likelihood Ratio Test ◽  
Rank Test ◽  
Motor Deficits ◽  
Ratio Test ◽  
Signed Rank ◽  
Wilcoxon Signed Rank Test ◽  
Signed Rank Test ◽  
Los Angeles Motor Scale

Introduction: The Los Angeles Motor Scale (LAMS) is a 3-item scale to identify motor deficits. This can identify severe strokes in the field so that patients can be transported appropriately. Methods: Prospective observational cohort study based in a county EMS system. Patients transported for stroke had a LAMS administered in the field. Outcome data from individual receiving hospitals collected within 45 days of the event. Results: Our cohort (n=2374) had a median age of 72 and was 51% female. 19% had LAMS 0, 14% LAMS 1, 13% LAMS 2, 17% LAMS 3, 16% LAMS 4, and 21% had LAMS 5. We generated three receiver operating characteristic curves for the interventions of mechanical intervention, tPA, and CTA perfusion imaging, with C statistics of .706, .632, and .668 respectively. All three models were significant using the likelihood ratio test, p < .0001. In all three models, the cut point was a LAMS of 4. Accordingly, a high LAMS was defined as 4 or 5, whereas a low LAMS was defined as <4. In the following table, all associations were significant with p < .0001 using the likelihood ratio test. The median NIHSS at hospital arrival was 6, IQR 2-13. For low LAMS it was 4 (IQR 1-8), and for high LAMS it was significantly greater at 13, IQR 7-21, p <.0001 using Wilcoxon’s rank-sum test. At hospital discharge, median NIHSS was 2, IQR 0-7. For low LAMS it was 1 (IQR 0-5), for high LAMS it was significantly greater at 5 (IQR 1-14.75), p < .0001 using Wilcoxon’s rank-sum test. Median NIHSS improvement was 2 points, p < .0001 (Wilcoxon signed-rank test). The differences were significant with p < .0001 for both low LAMS and high LAMS patients individually (Wilcoxon signed-rank test). Low LAMS patients had a median improvement of 1.5 points. High LAMS patients had a significantly greater median improvement of 4 points (p < .0001 using Wilcoxon rank-sum test), likely because they generally started out in worse condition. Conclusion: The LAMS is a powerful prehospital predictor of intervention and outcomes after acute stroke.

Abstract WMP112: Cilostazol versus Aspirin for Secondary Stroke Prevention: Systematic Review and Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Michelle P Lin ◽  
Kevin M Barrett ◽  
James F Meschia ◽  
Benjamin H Eidelman ◽  
Josephine F Huang ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Trials ◽  
Ischemic Stroke ◽  
Random Effects ◽  
Intracranial Hemorrhage ◽  
Stroke Prevention ◽  
Lower Risk ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Secondary Stroke Prevention

Introduction: Cilostazol has promise as an alternative to aspirin for secondary stroke prevention given its vasodilatory and anti-inflammatory properties in addition to platelet aggregation inhibition. We conducted a systematic review and meta-analysis to estimate the comparative effectiveness and safety of cilostazol compared to aspirin for stroke prevention in patients with previous stroke or TIA. Hypothesis: Cilostazol is more effective than aspirin in preventing recurrent ischemic stroke with lower risk of intracranial hemorrhage and bleeding. Methods: We searched PubMed and the Cochrane Central Register of Controlled Trials from inception to 2019. Randomized clinical trials that compared cilostazol vs aspirin and reported the endpoints of ischemic stroke, intracranial hemorrhage and bleeding were included. A random-effects estimate was computed based on Mantel-Haenszel methods. The pooled estimates with 95% confidence intervals were compared between cilostazol and aspirin and displayed as forest plots (Figure). Results: The search identified 5 randomized clinical trials comparing cilostazol vs aspirin for secondary stroke prevention that enrolled 7,240 patients from primarily Asian countries (3,615 received cilostazol and 3,625 received aspirin). The pooled results from the random-effects model showed that cilostazol was associated with significantly lower risk of recurrent ischemic stroke (Hazard ratio [HR] 0.70; 95%CI, 0.54-0.89), intracranial hemorrhage (HR 0.41; 95%CI, 0.25-0.65) and bleeding (HR 0.71; 95%CI, 0.55-0.91). See forest plots. Conclusion: This meta-analysis suggests cilostazol is more effective than aspirin in the prevention of recurrent ischemic stroke with lower risk of intracranial hemorrhage and bleeding. Confirmatory randomized trials of cilostazol for secondary stroke prevention to be performed in more generalizable populations are needed.

Abstract 13215: Gender-affirming Hormones Are Associated With Increased Risk of QT Prolongation in Transgender Females

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Daniel Antwi Amoabeng ◽  
Ahmed Hanfy ◽  
Munadel Awad ◽  
Bryce D Beutler ◽  
Amneet Rai ◽  
...  
Keyword(s):  
Qt Interval ◽  
Small Sample Size ◽  
Qt Prolongation ◽  
Small Sample ◽  
Rank Test ◽  
Qt Interval Prolongation ◽  
Northern Nevada ◽  
Increased Risk ◽  
Before And After ◽  
Signed Rank Test

Introduction: Women have a longer QT interval than men. This sex-specific difference is attributed to hormones associated with the biological female sex. Male-to-female transgender individuals often take antiandrogens such as spironolactone or goserelin in addition to estrogens to suppress testosterone effects while increasing feminine features. Effects of gender-affirming hormone therapy (GHT) on the QT interval in these individuals remains to be elucidated. Hypothesis: We assessed the hypothesis that the use of GHT is associated with an increased risk for QT interval prolongation in transgender females. Methods: We identified 46 transgender females through a search of the electronic medical records of a Veterans Administration hospital in Northern Nevada. Patients with a diagnosis of congenital long QT syndrome were excluded. Of these, 13 patients had ECGs before and after initiation of GHT and were included. We adapted the Tisdale score using the auto-calculated corrected QT interval (QTc) to estimate the risk of QT prolongation. Age, QTc, and Tisdale scores before and after GHT initiation were compared using the Wilcoxon signed-rank test. All tests were performed as two-tailed at a 5% level of significance. Results: All 13 study patients were taking estrogens. Of these, 3 (23.1%) were taking goserelin and 9 (69.2%) were taking spironolactone. Mean ± SEM age at ECG acquisition was 45.0 ± 4.4 and 47.7 ± 4.7 years before and after the initiation of GHT respectively. Mean ± SEM QTc after initiation of GHT was significantly higher compared to the baseline (467.5 ± 12.8 ms vs. 428.2 ± 7.1 ms) (Figure 1A). The average baseline Tisdale score was significantly smaller on follow-up (1-point vs. 3 points) (Figure 1B). Conclusions: GHT appears to be associated with increased QTc in transgender women. This needs to be interpreted with caution owing to the very small sample size in this study. Further studies to investigate the strength of this association, if it exists, are warranted.

Improved Postoperative Survival for Intraductal- Growth Subtype of Intrahepatic Cholangiocarcinoma

2016 ◽  
Vol 82 (11) ◽  
pp. 1133-1139 ◽  
Author(s):  
Laura L. Dover ◽  
Rojymon Jacob ◽  
Thomas N. Wang ◽  
Joseph H. Richardson ◽  
David T. Redden ◽  
...  
Keyword(s):  
Intrahepatic Cholangiocarcinoma ◽  
Small Sample Size ◽  
Tumor Stage ◽  
Small Sample ◽  
Postoperative Survival ◽  
Rank Test ◽  
Intraductal Growth ◽  
Kaplan Meier ◽  
Disease Free

Intrahepatic cholangiocarcinoma (ICC) is classified according to the following subtypes: mass-forming (MF), periductal infiltrating (PI), and intraductal growth (IG). The aim of this study is to measure the association between ICC subtypes and patient survival after surgical resection. Data were abstracted on all patients treated with definitive resections of ICC at a single institution between 2000 and 2011 with at least three years follow-up. Survival estimates were quantified using Kaplan-Meier curves and compared using the log-rank test. There were 37 patients with ICC treated with definitive partial hepatectomies with a median survival of 33.5 months. Tumor stage (P < 0.0001), satellitosis (P < 0.001), lymphovascular space invasion (P = 0.003), and macroscopic subtype (P = 0.003) were predictive of postoperative survival. Disease-free survivals for MF, PI, and IG subtypes, respectively, were 30 per cent, 0 per cent, and 57 per cent (P = 0.017). Overall survivals among ICC macroscopic subtypes were as follows: MF 37 per cent, PI 0 per cent, and IG 71 per cent (P = 0.003). Although limited by the small sample size of this rare cancer, this study demonstrates significant differences among macroscopic subtypes of ICC in both disease-free survivals and overall survivals after definitive partial hepatectomy.

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