THE EFFECT OF TRANSDERMAL GLYCERYL TRINITRATE IN ACUTE STROKE PATIENTS WITH CAROTID STENOSIS: DATA FROM THE EFFICACY OF NITRIC OXIDE IN STROKE TRIAL

Background High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Aims Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Methods Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Results Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. Conclusion It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. Trial registration ISRCTN26986053.

Download Full-text

RAPID INTERVENTION WITH GLYCERYL TRINITRATE IN HYPERTENSIVE STROKE TRIAL-2 (RIGHT-2): SAFETY AND EFFICACY OF TRANSDERMAL GLYCERYL TRINITRATE, A NITRIC OXIDE DONOR

Emergency Medicine Journal ◽

10.1136/emermed-2016-206139.42 ◽

2016 ◽

Vol 33 (9) ◽

pp. e13.2-e14 ◽

Cited By ~ 1

Author(s):

Philip M W Bath ◽

Mark Dixon ◽

Jason Appleton ◽

Polly Scutt ◽

Timothy England ◽

...

Keyword(s):

Nitric Oxide ◽

Glyceryl Trinitrate ◽

Nitric Oxide Donor ◽

Safety And Efficacy ◽

Stroke Trial

Download Full-text

It is safe to use transdermal glyceryl trinitrate to lower blood pressure in patients with acute ischaemic stroke with carotid stenosis

Stroke and Vascular Neurology ◽

10.1136/svn-2019-000232 ◽

2019 ◽

Vol 4 (1) ◽

pp. 28-35 ◽

Cited By ~ 1

Author(s):

Jason P Appleton ◽

Lisa J Woodhouse ◽

Andrew Belcher ◽

Daniel Bereczki ◽

Eivind Berge ◽

...

Keyword(s):

Blood Pressure ◽

Ischaemic Stroke ◽

Glyceryl Trinitrate ◽

Acute Stroke ◽

Carotid Stenosis ◽

Primary Outcome ◽

Lower Blood ◽

Bilateral Carotid ◽

Using Data

BackgroundThere is concern that blood pressure (BP) lowering in acute stroke may compromise cerebral perfusion and worsen outcome in the presence of carotid stenosis. We assessed the effect of glyceryl trinitrate (GTN) in patients with carotid stenosis using data from the Efficacy of Nitric Oxide in Stroke (ENOS) Trial.MethodsENOS randomised 4011 patients with acute stroke and raised systolic BP (140–220 mm Hg) to transdermal GTN or no GTN within 48 hours of onset. Those on prestroke antihypertensives were also randomised to stop or continue their medication for 7 days. The primary outcome was the modified Rankin Scale (mRS) at day 90. Ipsilateral carotid stenosis was split: <30%; 30–<50%; 50–<70%; ≥70%. Data are ORs with 95% CIs adjusted for baseline prognostic factors.Results2023 (60.5%) ischaemic stroke participants had carotid imaging. As compared with <30%, ≥70% ipsilateral stenosis was associated with an unfavourable shift in mRS (worse outcome) at 90 days (OR 1.88, 95% CI 1.44 to 2.44, p<0.001). Those with ≥70% stenosis who received GTN versus no GTN had a favourable shift in mRS (OR 0.56, 95% CI 0.34 to 0.93, p=0.024). In those with 50–<70% stenosis, continuing versus stopping prestroke antihypertensives was associated with worse disability, mood, quality of life and cognition at 90 days. Clinical outcomes did not differ across bilateral stenosis groups.ConclusionsFollowing ischaemic stroke, severe ipsilateral carotid stenosis is associated with worse functional outcome at 90 days. GTN appears safe in ipsilateral or bilateral carotid stenosis, and might improve outcome in severe ipsilateral carotid stenosis.

Download Full-text

Carotid Artery Stenosis Is Associated with Better Intracranial Collateral Circulation in Stroke Patients

Cerebrovascular Diseases ◽

10.1159/000506826 ◽

2020 ◽

Vol 49 (2) ◽

pp. 200-205

Author(s):

Juha-Pekka Pienimäki ◽

Niko Sillanpää ◽

Pasi Jolma ◽

Sara Protto

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Clinical Outcome ◽

Acute Stroke ◽

Carotid Stenosis ◽

Carotid Artery Stenosis ◽

Collateral Circulation ◽

Artery Stenosis ◽

Stroke Patients ◽

Significant Difference

Background: Adequate collateral circulation improves the clinical outcome of ischemic stroke patients. We evaluated the influence of ipsilateral carotid stenosis on intracranial collateral circulation in acute stroke patients. Methods: We collected the data of 385 consecutive acute stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) imaging in a single high-volume stroke center. Patients with occlusion of the first segment (M1) segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of carotid stenosis on intracranial collateral circulation was studied with appropriate statistical tests and ordinal regression analysis. Results: Fifty out of the 247 patients eligible for analysis had severe ipsilateral carotid stenosis (≥75%). These patients were 4-times more likely to have very good intracranial collaterals (Collateral Score 3–4, p = 0.001) than the nonstenotic and slightly stenotic (<75%) patients. The severely stenotic patients had a longer mean operation time (41 vs. 29 min to reperfusion, respectively, p = 0.001). Nevertheless, 54% of severely stenotic patients had good 3-month clinical outcome (modified Rankin Scale ≤2) with no significant difference between the 2 groups. Conclusions: Carotid artery stenosis of over 75% of vessel diameter was associated with better intracranial collateral circulation of patients with acute ischemic stroke. This did not significantly change the 3-month clinical outcome.

Download Full-text

Abstract 163: Carotid Stenosis and Stroke Recurrence in Minor Stroke Patients With Atrial Fibrillation

Stroke ◽

10.1161/str.45.suppl_1.163 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Shigeru Fujimoto ◽

Masato Ohsaki ◽

Masaya Kumamoto ◽

Takao Ishitsuka ◽

Takanari Kitazono

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Carotid Stenosis ◽

Positive Association ◽

Artery Stenosis ◽

Minor Stroke ◽

Stroke Recurrence ◽

Stroke Patients ◽

Antithrombotic Treatment ◽

D Dimer

Background & Purpose: Both atrial fibrillation (AF) and carotid stenosis (CS) can be associated with acute stroke recurrence and consequent bad outcome even in minor stroke. We investigated stroke recurrence and outcome in Japanese minor stroke patients with AF and/or CS. Subjects & Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 7 days after the onset, 634 patients with acute ischemic stroke with AF, the initial NIH stroke scale score of 7 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. We observed an acute stroke recurrence during 3 weeks. Results: Acute stroke recurrence was observed in 27 (4.3%) patients. Major cerebral artery stenosis of 50% or more in diameter was observed in 159 (25.1%) patients, and among them 43 (6.8%) had carotid stenosis. Any major artery stenosis was more frequent in patients with than without stroke recurrence (55.6% vs 23.7%, p=0.0002). Carotid stenosis was more frequent in patients with than without stroke recurrence (25.9% vs 5.9%, p<0.0001). The initial NIHSS score was not different between patients with and without an acute stroke recurrence. Dyslipidemia, diabetes mellitus, and history of brain hemorrhage were more frequent, and HDL cholesterol and estimated GFR values were lower, and HbA1c, fasting glucose, BUN, and D-dimer values were higher, intima-media thickness 0f the common carotid artery was thicker in patients with than without an acute stroke recurrence. On the multivariate analysis, carotid stenosis (OR 4.93, 95%CI 1.60~15.2) and D-dimer value (OR 1.13, 95%CI 1.00~1.28) had a positive association with an acute stroke recurrence. Among 43 patients with both AF and CS, 7 had an acute stroke recurrence. With regard to the acute antithrombotic treatment, 5 patients were treated with only anticoagulant agents and other 2 patients were treated with both anticoagulant and antiplatelet agents. Conclusions: Carotid stenosis was a significant predictor for an acute stroke recurrence in patients with atrial fibrillation. Optimal antithrombotic treatment in the acute phase in stroke patients with both AF and CS should be investigated.

Download Full-text