RESUMO
Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.
Assuntos
Ataque Isquêmico Transitório , AVC Isquêmico , Guias de Prática Clínica como Assunto , Prevenção Secundária , Humanos , American Heart Association , Europa (Continente) , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/diagnóstico , AVC Isquêmico/prevenção & controle , AVC Isquêmico/diagnóstico , Prevenção Secundária/métodos , Prevenção Secundária/normas , Estados UnidosRESUMO
Atrial fibrillation (AF) is the primary cause of ischaemic stroke and transient ischaemic attack (TIA). AF is associated with a high risk of recurrence, which can be reduced using optimal prevention strategies, mainly anticoagulant therapy. The availability of effective prophylaxis justifies the need for a significant, coordinated and thorough transdisciplinary effort to screen for AF associated with stroke. A recent French national survey, initiated and supported by the Société française neurovasculaire (SFNV) and the Société française de cardiologie (SFC), revealed many shortcomings, such as the absence or inadequacy of telemetry equipment in more than half of stroke units, insufficient and highly variable access to monitoring tools, delays in performing screening tests, heterogeneous access to advanced or connected ambulatory monitoring techniques, and a lack of dedicated human resources. The present scientific document has been prepared on the initiative of the SFNV and the SFC with the aim of helping to address the current shortcomings and gaps, to promote efficient and cost-effective AF detection, and to improve and, where possible, homogenize the quality of practice in AF screening among stroke units and outpatient post-stroke care networks. The working group, composed of cardiologists and vascular neurologists who are experts in the field and are nominated by their peers, reviewed the literature to propose statements, which were discussed in successive cycles, and maintained, either by consensus or by vote, as appropriate. The text was then submitted to the SFNV and SFC board members for review. This scientific statement document argues for the widespread development of patient pathways to enable the most efficient AF screening after stroke. This assessment should be carried out by a multidisciplinary team, including expert cardiologists and vascular neurologists.
Assuntos
Fibrilação Atrial , Consenso , Ataque Isquêmico Transitório , AVC Isquêmico , Valor Preditivo dos Testes , Humanos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Fibrilação Atrial/fisiopatologia , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/terapia , Ataque Isquêmico Transitório/prevenção & controle , AVC Isquêmico/diagnóstico , AVC Isquêmico/etiologia , AVC Isquêmico/prevenção & controle , AVC Isquêmico/terapia , Fatores de Risco , França/epidemiologia , Cardiologia/normas , Prognóstico , Cardiologistas , RecidivaRESUMO
For patients presenting with a cerebral episode of vascular origin whose pathogenetic mechanism is due to large vessel disease affecting the carotid arteries, different intervention strategies for secondary prophylaxis are available: medical (single or dual antiplatelet therapy), surgical or endovascular. In this review, these strategies will be described, along with suggestions for appropriate application in clinical practice. These suggestions may vary depending on whether early or long-term secondary prophylaxis is considered.
Assuntos
Doenças das Artérias Carótidas , Ataque Isquêmico Transitório , Inibidores da Agregação Plaquetária , Prevenção Secundária , Acidente Vascular Cerebral , Humanos , Prevenção Secundária/métodos , Doenças das Artérias Carótidas/complicações , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/etiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Endarterectomia das Carótidas/métodosRESUMO
BACKGROUND: Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem. METHODS AND RESULTS: Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels. CONCLUSIONS: Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.
Assuntos
Anticoagulantes , Fibrilação Atrial , Adesão à Medicação , Acidente Vascular Cerebral , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Masculino , Feminino , Estudos Retrospectivos , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Idoso , Adesão à Medicação/estatística & dados numéricos , Administração Oral , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Pessoa de Meia-Idade , Fatores de Tempo , Idoso de 80 Anos ou mais , Resultado do Tratamento , Embolia/prevenção & controle , Embolia/epidemiologia , Embolia/etiologia , Fatores de Risco , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controleRESUMO
BACKGROUND: Short and rare episodes of atrial fibrillation (AF) are commonly detected using implanted devices (device-detected AF) in patients with prior stroke or transient ischemic attack (TIA). The effectiveness and safety of oral anticoagulation in patients with prior stroke or TIA and device-detected AF but with no ECG-documented AF is unclear. METHODS AND RESULTS: This prespecified analysis of the NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes) trial with post hoc elements assessed the effect of oral anticoagulation in patients with device-detected AF with and without a prior stroke or TIA in the randomized, double-blind, double-dummy NOAH-AFNET 6 trial. Outcomes were stroke, systemic embolism, and cardiovascular death (primary outcome) and major bleeding and death (safety outcome). A prior stroke or TIA was found in 253 patients with device-detected AF randomized in the NOAH-AFNET 6 (mean age, 78 years; 36.4% women). There was no treatment interaction with prior stroke or TIA for any of the primary and secondary time-to-event outcomes. In patients with a prior stroke or TIA, 14 out of 122 patients experienced a primary outcome event with anticoagulation (5.7% per patient-year). Without anticoagulation, there were 16 out of 131 patients with an event (6.3% per patient-year). The rate of stroke was lower than expected (anticoagulation: 4 out of 122 [1.6% per patient-year]; no anticoagulation: 6 out of 131 [2.3% per patient-year]). Numerically, there were more major bleeding events with anticoagulation in patients with prior stroke or TIA (8 out of 122 patients) than without anticoagulation (2 out of 131 patients). CONCLUSIONS: Anticoagulation appears to have ambiguous effects in patients with device-detected AF and a prior stroke or TIA in this hypothesis-generating analysis of the NOAH-AFNET 6 in the absence of ECG-documented AF, partially due to a low rate of stroke without anticoagulation.
Assuntos
Anticoagulantes , Fibrilação Atrial , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/etiologia , Feminino , Idoso , Masculino , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Método Duplo-Cego , Administração Oral , Idoso de 80 Anos ou mais , Resultado do Tratamento , Hemorragia/induzido quimicamente , Fatores de Tempo , Marca-Passo ArtificialRESUMO
BACKGROUND: Few individuals (<2%) who experience a stroke or transient ischemic attack (TIA) participate in secondary prevention lifestyle programs. Novel approaches that leverage digital health technology may provide a viable alternative to traditional interventions that support secondary prevention in people living with stroke or TIA. To be successful, these strategies should focus on user needs and preferences and be acceptable to clinicians and people living with stroke or TIA. OBJECTIVE: This study aims to co-design, with people with lived experience of stroke or TIA (referred to as consumers) and clinicians, a multicomponent digital technology support program for secondary prevention of stroke. METHODS: A consumer user needs survey (108 items) was distributed through the Australian Stroke Clinical Registry and the Stroke Association of Victoria. An invitation to a user needs survey (135 items) for clinicians was circulated via web-based professional forums and national organizations (eg, the Stroke Telehealth Community of Practice Microsoft Teams Channel) and the authors' research networks using Twitter (subsequently rebranded X, X Corp) and LinkedIn (LinkedIn Corp). Following the surveys, 2 rounds of user experience workshops (design and usability testing workshops) were completed with representatives from each end user group (consumers and clinicians). Feedback gathered after each round informed the final design of the digital health program. RESULTS: Overall, 112 consumers (male individuals: n=63, 56.3%) and 54 clinicians (female individuals: n=43, 80%) responded to the survey; all items were completed by 75.8% (n=85) of consumers and 78% (n=42) of clinicians. Most clinicians (46/49, 94%) indicated the importance of monitoring health and lifestyle measures more frequently than current practice, particularly physical activity, weight, and sleep. Most consumers (87/96, 90%) and clinicians (41/49, 84%) agreed that providing alerts about potential deterioration in an individual's condition were important functions for a digital program. Intention to use a digital program for stroke prevention and discussing the data collected during face-to-face consultations was high (consumers: 79/99, 80%; clinicians 36/42, 86%). In addition, 7 consumers (male individuals: n=5, 71%) and 9 clinicians (female individuals: n=6, 67%) took part in the user experience workshops. Participants endorsed using a digital health program to help consumers manage stroke or TIA and discussed preferred functions and health measures in a digital solution for secondary prevention of stroke. They also noted the need for a mobile app that is easy to use. Clinician feedback highlighted the need for a customizable clinician portal that captures individual consumer goals. CONCLUSIONS: Following an iterative co-design process, supported by evidence from user needs surveys and user experience workshops, a consumer-facing app that integrates wearable activity trackers and a clinician web portal were designed and developed to support secondary prevention of stroke. Feasibility testing is currently in progress to assess acceptability and use.
Assuntos
Saúde Digital , Ataque Isquêmico Transitório , Prevenção Secundária , Acidente Vascular Cerebral , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Austrália , Tecnologia Biomédica/métodos , Tecnologia Digital , Ataque Isquêmico Transitório/prevenção & controle , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Inquéritos e Questionários , TelemedicinaRESUMO
BACKGROUND: Individuals with diabetes exhibit a higher risk of cardiovascular disease and mortality compared to healthy individuals. Following a transient ischemic attack (TIA) the risk of stroke and death increase further. Physical activity engagement after a TIA is an effective way of secondary prevention. However, there's a lack of research on how individuals with diabetes modify physical activity levels and how these adjustments impact survival post-TIA. This study aimed to determine the extent to which individuals with diabetes alter their physical activity levels following a TIA and to assess the impact of these changes on mortality. METHODS: This was a nationwide longitudinal study, employing data from national registers in Sweden spanning from 01/01/2003 to 31/12/2019. Data were collected 2 years retro- and prospectively of TIA occurrence, in individuals with diabetes. Individuals were grouped based on decreasing, remaining, or increasing physical activity levels after the TIA. Cox proportional hazards models were fitted to evaluate the adjusted relationship between change in physical activity and all-cause, cardiovascular, and non-cardiovascular mortality. RESULTS: The final study sample consisted of 4.219 individuals (mean age 72.9 years, 59.4% males). Among them, 35.8% decreased, 37.5% kept steady, and 26.8% increased their physical activity after the TIA. A subsequent stroke occurred in 6.7%, 6.4%, and 6.1% of individuals, while death occurred in 6.3%, 7.3%, and 3.7% of individuals, respectively. In adjusted analyses, participants who increased their physical activity had a 45% lower risk for all-cause mortality and a 68% lower risk for cardiovascular mortality, compared to those who decreased their physical activity. CONCLUSIONS: Positive change in physical activity following a ΤΙΑ was associated with a reduced risk of mortality. Increased engagement in physical activity should be promoted after TIA, thereby actively supporting individuals with diabetes in achieving improved health outcomes.
Assuntos
Diabetes Mellitus , Exercício Físico , Ataque Isquêmico Transitório , Sistema de Registros , Comportamento de Redução do Risco , Humanos , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/epidemiologia , Masculino , Feminino , Idoso , Suécia/epidemiologia , Estudos Longitudinais , Medição de Risco , Pessoa de Meia-Idade , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidade , Diabetes Mellitus/epidemiologia , Idoso de 80 Anos ou mais , Fatores de Tempo , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Prevenção Secundária , Resultado do Tratamento , Fatores de Proteção , Estudos Retrospectivos , Causas de Morte , RecidivaRESUMO
BACKGROUND: Moyamoya disease (MMD) is a significant cause of childhood stroke and transient ischemic attacks (TIAs). This study aimed to assess the safety and efficacy of remote ischemic conditioning (RIC) in children with MMD. METHODS: In a single-center pilot study, 46 MMD patients aged 4 to 14 years, with no history of reconstructive surgery, were randomly assigned to receive either RIC or sham RIC treatment twice daily for a year. The primary outcome measured was the cumulative incidence of major adverse cerebrovascular events (MACEs). Secondary outcomes included ischemic stroke, recurrent TIA, hemorrhagic stroke, revascularization rates, and clinical improvement assessed using the patient global impression of change (PGIC) scale during follow-up. RIC-related adverse events were also recorded, and cerebral hemodynamics were evaluated using transcranial Doppler. RESULTS: All 46 patients completed the final follow-up (23 each in the RIC and sham RIC groups). No severe adverse events associated with RIC were observed. Kaplan-Meier analysis indicated a significant reduction in MACEs frequency after RIC treatment [log-rank test (Mantel-Cox), P = 0.021]. At 3-year follow-up, two (4.35%) patients had an ischemic stroke, four (8.70%) experienced TIAs, and two (4.35%) underwent revascularization as the qualifying MACEs. The clinical improvement rate in the RIC group was higher than the sham RIC group on the PGIC scale (65.2% vs. 26.1%, P < 0.01). No statistical difference in cerebral hemodynamics post-treatment was observed. CONCLUSIONS: RIC is a safe and effective adjunct therapy for asymptomatic children with MMD. This was largely due to the reduced incidence of ischemic cerebrovascular events.
Assuntos
Doença de Moyamoya , Humanos , Doença de Moyamoya/complicações , Doença de Moyamoya/terapia , Criança , Masculino , Feminino , Pré-Escolar , Adolescente , Projetos Piloto , Precondicionamento Isquêmico/métodos , Resultado do Tratamento , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/etiologia , Isquemia Encefálica/prevenção & controle , Isquemia Encefálica/etiologiaRESUMO
BACKGROUND: Adherence to post-stroke secondary prevention medications mitigates recurrence risk. This study aimed to measure adherence to secondary prevention medications during 3 years post-ischemic stroke/transient ischemic attack, using prescription and dispensing data, and identify factors associated with suboptimal adherence. METHODS: This multicenter, prospective, cohort study involved patients from the STROKE 69 cohort, which included all consecutive patients with suspected acute stroke admitted between November 2015 and December 2016 to any emergency department or stroke center in the Rhône area in France. Prescription data for antihypertensive agents, antidiabetic agents, lipid-lowering drugs, and antithrombotics were collected. Dispensing data were provided by the French regional reimbursement database. Adherence was calculated using the continuous medication acquisition index. Associations between suboptimal adherence and potential influencing factors across the World Health Organization's five dimensions were explored through univariate and multivariate analyses. RESULTS: From 1512 eligible patients, 365 were included. Optimal adherence to overall treatment (≥90%) was observed in 61%, 62%, and 65% of patients in the first, second, and third years, respectively. Education level (high school diploma or higher: OR = 3.24, 95% CI [1.49; 7.36]) and depression (Hospital Anxiety and Depression Scale-Depression scores 8-10: OR = 1.90, 95% CI [1.05; 3.44]) were significantly associated with suboptimal adherence. CONCLUSIONS: Overall adherence to secondary prevention medications was fairly good. Having an initial diagnosis of transient ischemic attack, a high level of education, or depression was associated with increased odds of suboptimal adherence, while having a history of heart rhythm disorder was associated with lower odds.
Assuntos
Anti-Hipertensivos , Ataque Isquêmico Transitório , Adesão à Medicação , Prevenção Secundária , Acidente Vascular Cerebral , Humanos , Feminino , Masculino , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/prevenção & controle , Idoso , Prevenção Secundária/métodos , Adesão à Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/prevenção & controle , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Estudos de Coortes , Estudos Prospectivos , França/epidemiologia , Hipoglicemiantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Hipolipemiantes/uso terapêuticoRESUMO
BACKGROUND: Sneddon syndrome is an occlusive vasculopathy that presents clinically with generalized livedo racemosa on the skin and transient ischemic attacks, strokes, and cognitive or motor deficits in the central nervous system. Antiplatelet or anticoagulant therapy is recommended. Due to the limited therapeutic efficacy and the resulting serious complications, we propose combination therapy with additional infusion cycles of alprostadil and captopril and report initial long-term results. PATIENTS AND METHODS: We performed a systematic retrospective analysis of all patients with primary Sneddon syndrome who received combination therapy in our clinic between 1995 and 2020. Therapeutic outcomes were evaluated using descriptive statistics compared to historical controls receiving monotherapy. We also analyzed the event rate of complications when combination therapy was discontinued. RESULTS: During the 99.7 patient-years of follow-up, there were no transient ischemic attacks and the stroke rate dropped to 0.02 per patient-year. In comparison, the rates of transient ischemic attacks and strokes in the historical controls ranged from 0.08 to 0.035 per patient-year. After discontinuation of alprostadil therapy, eight events occurred in three patients. CONCLUSIONS: Combination therapy reduces the long-term incidence of ischemic events in patients with primary Sneddon syndrome.
Assuntos
Alprostadil , Quimioterapia Combinada , Síndrome de Sneddon , Humanos , Feminino , Estudos Retrospectivos , Masculino , Síndrome de Sneddon/epidemiologia , Síndrome de Sneddon/tratamento farmacológico , Pessoa de Meia-Idade , Adulto , Incidência , Alprostadil/uso terapêutico , Alprostadil/administração & dosagem , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/tratamento farmacológico , Resultado do Tratamento , Transtornos Cerebrovasculares/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Vasodilatadores/uso terapêutico , Vasodilatadores/administração & dosagem , IdosoRESUMO
AIMS: Subclinical atrial fibrillation (AF) is associated with increased risk of progression to clinical AF, stroke, and cardiovascular death. We hypothesized that in pacemaker patients requiring dual-chamber rate-adaptive (DDDR) pacing, closed loop stimulation (CLS) integrated into the circulatory control system through intra-cardiac impedance monitoring would reduce the occurrence of atrial high-rate episodes (AHREs) compared with conventional DDDR pacing. METHODS AND RESULTS: Patients with sinus node dysfunctions (SNDs) and an implanted pacemaker or defibrillator were randomly allocated to dual-chamber CLS (n = 612) or accelerometer-based DDDR pacing (n = 598) and followed for 3 years. The primary endpoint was time to the composite endpoint of the first AHRE lasting ≥6 min, stroke, or transient ischaemic attack (TIA). All AHREs were independently adjudicated using intra-cardiac electrograms. The incidence of the primary endpoint was lower in the CLS arm (50.6%) than in the DDDR arm (55.7%), primarily due to the reduction in AHREs lasting between 6 h and 7 days. Unadjusted site-stratified hazard ratio (HR) for CLS vs. DDDR was 0.84 [95% confidence interval (CI), 0.72-0.99; P = 0.035]. After adjusting for CHA2DS2-VASc score, the HR remained 0.84 (95% CI, 0.71-0.99; P = 0.033). In subgroup analyses of AHRE incidence, the incremental benefit of CLS was greatest in patients without atrioventricular block (HR, 0.77; P = 0.008) and in patients without AF history (HR, 0.73; P = 0.009). The contribution of stroke/TIA to the primary endpoint (1.3%) was low and not statistically different between study arms. CONCLUSION: Dual-chamber CLS in patients with SND is associated with a significantly lower AHRE incidence than conventional DDDR pacing.
Assuntos
Fibrilação Atrial , Estimulação Cardíaca Artificial , Frequência Cardíaca , Ataque Isquêmico Transitório , Marca-Passo Artificial , Síndrome do Nó Sinusal , Acidente Vascular Cerebral , Humanos , Feminino , Masculino , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Fibrilação Atrial/epidemiologia , Idoso , Síndrome do Nó Sinusal/terapia , Síndrome do Nó Sinusal/fisiopatologia , Estimulação Cardíaca Artificial/métodos , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/epidemiologia , Pessoa de Meia-Idade , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/epidemiologia , Incidência , Resultado do Tratamento , Fatores de Tempo , Fatores de Risco , Desfibriladores Implantáveis , Técnicas Eletrofisiológicas Cardíacas , Acelerometria , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Anti-inflammatory therapy with long-term colchicine prevented vascular recurrence in coronary disease. Unlike coronary disease, which is typically caused by atherosclerosis, ischaemic stroke is caused by diverse mechanisms including atherosclerosis and small vessel disease or is frequently due to an unknown cause. We aimed to investigate the hypothesis that long-term colchicine would reduce recurrent events after ischaemic stroke. METHODS: We did a randomised, parallel-group, open-label, blinded endpoint assessed trial comparing long-term colchicine (0·5 mg orally per day) plus guideline-based usual care with usual care only. Hospital-based patients with non-severe, non-cardioembolic ischaemic stroke or high-risk transient ischaemic attack were eligible. The primary endpoint was a composite of first fatal or non-fatal recurrent ischaemic stroke, myocardial infarction, cardiac arrest, or hospitalisation (defined as an admission to an inpatient unit or a visit to an emergency department that resulted in at least a 24 h stay [or a change in calendar date if the hospital admission or discharge times were not available]) for unstable angina. The p value for significance was 0·048 to adjust for two prespecified interim analyses conducted by the data monitoring committee, for which the steering committee and trial investigators remained blinded. The trial was registered at ClinicalTrials.gov (NCT02898610) and is completed. FINDINGS: 3154 patients were randomly assigned between Dec 19, 2016, and Nov 21, 2022, with the last follow-up on Jan 31, 2024. The trial finished before the anticipated number of outcomes was accrued (367 outcomes planned) due to budget constraints attributable to the COVID-19 pandemic. Ten patients withdrew consent for analysis of their data, leaving 3144 patients in the intention-to-treat analysis: 1569 (colchicine and usual care) and 1575 (usual care alone). A primary endpoint occurred in 338 patients, 153 (9·8%) of 1569 patients allocated to colchicine and usual care and 185 (11·7%) of 1575 patients allocated to usual care alone (incidence rates 3·32 vs 3·92 per 100 person-years, hazard ratio 0·84; 95% CI 0·68-1·05, p=0·12). Although no between-group difference in C-reactive protein (CRP) was observed at baseline, patients treated with colchicine had lower CRP at 28 days and at 1, 2, and 3 years (p<0·05 for all timepoints). The rates of serious adverse events were similar in both groups. INTERPRETATION: Although no statistically significant benefit was observed on the primary intention-to-treat analysis, the findings provide new evidence supporting the rationale for anti-inflammatory therapy in further randomised trials. FUNDING: Health Research Board Ireland, Deutsche Forschungsgemeinschaft (German Research Foundation), and Fonds Wetenschappelijk Onderzoek Vlaanderen (Research Foundation Flanders), Belgium.
Assuntos
Colchicina , AVC Isquêmico , Prevenção Secundária , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Colchicina/administração & dosagem , Colchicina/uso terapêutico , Hospitalização/estatística & dados numéricos , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/tratamento farmacológico , AVC Isquêmico/prevenção & controle , Infarto do Miocárdio/prevenção & controle , Recidiva , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Surgical left atrial appendage (LAA) closure concomitant to open-heart surgery prevents thromboembolism in high-risk patients. Nevertheless, high-level evidence does not exist for LAA closure performed in patients with any CHA2DS2-VASc score and preoperative atrial fibrillation or flutter (AF) status-the current trial attempts to provide such evidence. METHODS: The study is designed as a randomized, open-label, blinded outcome assessor, multicenter trial of adult patients undergoing first-time elective open-heart surgery. Patients with and without AF and any CHA2DS2-VASc score will be enrolled. The primary exclusion criteria are planned LAA closure, planned AF ablation, or ongoing endocarditis. Before randomization, a three-step stratification process will sort patients by site, surgery type, and preoperative or expected oral anticoagulation treatment. Patients will undergo balanced randomization (1:1) to LAA closure on top of the planned cardiac surgery or standard care. Block sizes vary from 8 to 16. Neurologists blinded to randomization will adjudicate the primary outcome of stroke, including transient ischemic attack (TIA). The secondary outcomes include a composite outcome of stroke, including TIA, and silent cerebral infarcts, an outcome of ischemic stroke, including TIA, and a composite outcome of stroke and all-cause mortality. LAA closure is expected to provide a 60% relative risk reduction. In total, 1500 patients will be randomized and followed for 2 years. DISCUSSION: The trial is expected to help form future guidelines within surgical LAA closure. This statistical analysis plan ensures transparency of analyses and limits potential reporting biases. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03724318. Registered 26 October 2018, https://clinicaltrials.gov/study/NCT03724318 . PROTOCOL VERSION: https://doi.org/10.1016/j.ahj.2023.06.003 .
Assuntos
Apêndice Atrial , Fibrilação Atrial , Procedimentos Cirúrgicos Cardíacos , Acidente Vascular Cerebral , Feminino , Humanos , Masculino , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Fibrilação Atrial/complicações , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Interpretação Estatística de Dados , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/etiologia , Oclusão do Apêndice Atrial Esquerdo , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: This systematic review examines the effectiveness of motivational interviewing (MI) on medication adherence for preventing recurrent stroke and transient ischemic attack (TIA). METHODS: MEDLINE (via PubMed), CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov were searched from inception to 12 June 2023. Randomized controlled trials comparing MI with usual care or interventions without MI in participants with any stroke type were identified and summarized descriptively. Primary outcome was medication adherence. Secondary outcomes were quality of life (QoL) and different clinical outcomes. We assessed risk of bias with RoB 2 (revised Cochrane risk-of-bias tool) and intervention complexity with the iCAT_SR (intervention Complexity Assessment Tool for Systematic Reviews). RESULTS: We screened 691 records for eligibility and included four studies published in five articles. The studies included a total of 2751 participants, and three were multicentric. Three studies had a high risk of bias, and interventions varied in complexity. Two studies found significantly improved medication adherence, one at 9 (96.9% vs. 88.2%, risk ratio = 1.098, 95% confidence interval = 1.03-1.17) and one at 12 months (97.0% vs. 95.0%, p = 0.026), but not at other time points, whereas two other studies reported no significant changes. No significant differences were found in QoL or clinical outcomes. CONCLUSIONS: Evidence on MI appears inconclusive for improving medication adherence for recurrent stroke and TIA prevention, with no benefits on QoL and clinical outcomes. There is a need for robustly designed studies and process evaluations of MI as a complex intervention for people with stroke. REGISTRATION: PROSPERO (CRD42023433284).
Assuntos
Ataque Isquêmico Transitório , Adesão à Medicação , Entrevista Motivacional , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária , Acidente Vascular Cerebral , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Ataque Isquêmico Transitório/tratamento farmacológico , Entrevista Motivacional/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/tratamento farmacológico , Prevenção Secundária/métodos , RecidivaRESUMO
OBJECTIVES: Coptisine (Cop), an alkaloid isolated from Rhizoma Coptidis, has a protective effect against central nervous system diseases such as cerebral ischaemia-reperfusion (IR). Dysregulations in fatty acids metabolism are associated with neuroprotection and neuroinflammation. However, the effect of Cop on fatty acids metabolomics during anti-IR remains unclear. METHODS: Cerebral IR rats were established by middle cerebral artery occlusion, and the therapeutic effect of Cop was evaluated by 2, 3, 5-triphenytetrazolium chloride staining and neurological deficits scores. By liquid chromatography-tandem mass spectrometry (LC-MS/MS), fatty acids metabolomics analysis in ischaemic hemisphere and serum were investigated. RESULTS: We observed Cop (2 mg/kg/qd) was able to reduce cerebral infarct size and ameliorate the neurological function score. Meanwhile decrease in tumour necrosis factor-α (TNF-α), and interleukin-1ß (IL-1ß) after Cop treatment. Compared with control, down-regulation of cyclopentenone PGs (e.g., PGA2, PGJ2, and 15-deoxy- delta-12,14-PGJ2) was observed in cerebral IR, but upregulation of them when followed by Cop treatment. Similarly, we found the ratios of 14,15-dihydroxyeicosatrienoic acid(14,15-DHET)/arachidonic acid and 11,12-DHET/arachidonic acid was lower in cerebral IR injury relative to control, while their ratios were increased after Cop treatment. CONCLUSION: Our results indicated that Cop protect against cerebral IR injury, and its mechanism might be closely associated with antiinflammation and the regulation of arachidonic acid metabolism.
Assuntos
Ácido Araquidônico , Berberina , Infarto da Artéria Cerebral Média , Ratos Sprague-Dawley , Traumatismo por Reperfusão , Fator de Necrose Tumoral alfa , Animais , Berberina/farmacologia , Berberina/análogos & derivados , Ácido Araquidônico/metabolismo , Masculino , Ratos , Infarto da Artéria Cerebral Média/tratamento farmacológico , Infarto da Artéria Cerebral Média/metabolismo , Traumatismo por Reperfusão/tratamento farmacológico , Traumatismo por Reperfusão/metabolismo , Traumatismo por Reperfusão/prevenção & controle , Fator de Necrose Tumoral alfa/metabolismo , Fármacos Neuroprotetores/farmacologia , Interleucina-1beta/metabolismo , Modelos Animais de Doenças , Espectrometria de Massas em Tandem , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/metabolismo , Ataque Isquêmico Transitório/prevenção & controle , Metabolômica/métodos , Ácidos Graxos/metabolismoAssuntos
Aspirina , Clopidogrel , Ataque Isquêmico Transitório , AVC Isquêmico , Inibidores da Agregação Plaquetária , Recidiva , Prevenção Secundária , Humanos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Clopidogrel/uso terapêutico , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/prevenção & controle , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/prevenção & controle , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Prevenção Secundária/métodos , Prevenção Secundária/normas , Fatores de Tempo , Quimioterapia Combinada , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: The optimal antithrombotic strategies for patients with atrial fibrillation who experience ischemic stroke (IS) despite direct oral anticoagulant (DOAC) therapy remain inconclusive. This study compared outcomes for patients with DOAC treatment failure who changed or retained their prestroke DOAC. METHODS AND RESULTS: This retrospective cohort study analyzed data from the National Health Insurance Research Database from 2012 to 2020. Patients with atrial fibrillation who experienced IS during DOAC therapy were assigned to either (1) the DOAC-change group: changing prestroke DOAC or (2) the DOAC-retain group: retaining prestroke DOAC. The primary outcome was a composite of recurrent IS and transient ischemic attack. The secondary outcomes included intracranial hemorrhage, major bleeding, systemic thromboembolism, and all-cause death. Propensity score-based inverse probability of treatment weighting was applied to balance the baseline characteristics between the DOAC-change and DOAC-retain groups. The Cox proportional hazards model compared the risk of outcomes between the 2 groups. In total, 1979 patients were enrolled (609 DOAC-change patients and 1370 DOAC-retain patients). The incidence rates of recurrent IS or transient ischemic attack were 7.20 and 6.56 per 100 person-years in the DOAC-change and DOAC-retain groups, respectively (hazard ratio [HR], 1.07 [95% CI, 0.87-1.30]). A nonsignificantly higher incidence rate of intracranial hemorrhage was observed in the DOAC-change group compared with the DOAC-retain group (0.75 versus 0.53 per 100-person-years; HR, 1.49 [95% CI, 0.78-2.83]). The systemic thromboembolism, major bleeding, and death rates were comparable between the DOAC-change and DOAC-retain groups. CONCLUSIONS: Changing prestroke DOAC does not reduce the risk of recurrent cerebral ischemia in patients with atrial fibrillation who develop IS during DOAC therapy. However, future studies should continue to observe the potential trends of increased intracranial hemorrhage risk.
Assuntos
Fibrilação Atrial , Ataque Isquêmico Transitório , AVC Isquêmico , Acidente Vascular Cerebral , Tromboembolia , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controle , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , AVC Isquêmico/diagnóstico , AVC Isquêmico/epidemiologia , AVC Isquêmico/prevenção & controle , Estudos Retrospectivos , Anticoagulantes/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/complicações , Administração OralRESUMO
BACKGROUNDS: Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel for minor strokes or TIAs has been demonstrated in several RCTs. Whether drug selection for mono-antiplatelet therapy (MAPT) following DAPT may influence stroke recurrence has not been clarified, especially for patients with intracranial atherosclerosis stenosis (ICAS). The Thrombelastography Platelet Mapping (TEG-PM) assay claimed to be capable of monitoring platelet function secondary to antiplatelet therapy. PURPOSE: The aim of this study was to investigate the preventive role of TEG-PM in individualized drug selection for MAPT following DAPT in patients with minor stroke or TIA. METHODS: We retrospectively reviewed our patient database to identify individuals with minor stroke or TIA between February 2019 and July 2022. Patients were divided into ICAS and non-ICAS groups, and the efficacy and safety of TEG-PM-guided MAPT for stroke prevention after minor stroke or TIA were investigated in each group. RESULTS: ICAS patients with TEG-PM-guided MAPT had lower rates of recurrent stroke than patients without TEG-PM guidance during a mean follow-up period of 18.1 months (6.3% vs 15.2%; p = 0.04). Patients without ICAS also tended to benefit from TEG-PM-guided MAPT with lower rates of stroke recurrence (2.6% vs 8.7%; p = 0.02). No difference in the safety outcome of any bleeding events was observed in patients with TEG-PM-guided MAPT and those without (ICAS group, 2.1% vs 3.0%; p = 0.68; non-ICAS group, 1.3% vs 2.3%; p = 0.79). CONCLUSION: The TEG-PM could be a tangible preprocessing in drug selection for MAPT following DAPT in patients with minor strokes or TIAs, especially for those with non-stented ICASs.
Assuntos
Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/efeitos adversos , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/prevenção & controle , Tromboelastografia , Estudos Retrospectivos , Quimioterapia Combinada , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controleRESUMO
BACKGROUND: Following regulatory approval, medical devices may be used "off-label." Patent foramen ovale (PFO) closure is indicated to reduce recurrent stroke but has been proposed for other indications, including migraine, transient ischemic attack, and diving decompression illness. We sought to evaluate PFO closure rates and indications relative to the timing of regulatory approval and publication of key randomized trials. METHODS: We performed a retrospective cohort study using the OptumLabs Data Warehouse of US commercial insurance enrollees from 2006 to 2019. We quantified PFO closure among individuals with ≥2 years of preprocedure coverage to establish indications, classified hierarchically as stroke/systemic embolism, migraine, transient ischemia attack, or other. RESULTS: We identified 5315 patients undergoing PFO closure (51.8% female, 29.2%≥60 years old), which increased from 4.75 per 100â 000 person-years in 2006 to 6.60 per 100â 000 person-years in 2019. Patients aged ≥60 years accounted for 29.2% of closures. Procedure volumes corresponded weakly with supportive clinical publications and device approval. Among patients with PFO closure, 58.6% underwent closure for stroke/systemic embolism, 10.2% for transient ischemia attack, 8.8% for migraine, and 22.4% for other indications; 17.6% of patients had atrial fibrillation at baseline; and 11.9% developed atrial fibrillation postprocedure. Those aged ≥60 years and male were less likely to undergo closure for migraine than stroke/systemic embolism. CONCLUSIONS: From 2006 to 2019, PFO closure use was consistently low and corresponded weakly with clinical trial publications and regulatory status. Nearly half of patients underwent PFO closure for indications unapproved by the Food and Drug Administration. Regulators and payers should coordinate mechanisms to promote utilization for approved indications to ensure patient safety and should facilitate clinical trials for other possible indications.
Assuntos
Fibrilação Atrial , Embolia , Forame Oval Patente , Ataque Isquêmico Transitório , Transtornos de Enxaqueca , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Forame Oval Patente/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Cateterismo Cardíaco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Prevenção Secundária/métodos , IsquemiaRESUMO
BACKGROUND: Patients with minor ischemic stroke or transient ischemic attacks (TIAs) are often treated with dual antiplatelet therapy regimens as part of secondary stroke prevention. Clopidogrel, an antiplatelet used in these regimens, is metabolized into its active form by the CYP2C19 enzyme. Patients with loss of function (LOF) mutations in CYP2C19 are at risk for poorer secondary outcomes when prescribed clopidogrel. AIMS: We aimed to determine the cost-effectiveness of three different treatment antiplatelet regimens in ischemic stroke populations with minor strokes or TIAs and how these treatment regimens are influenced by the LOF prevalence in the population. METHODS: Markov models were developed to look at the cost-effectiveness of empiric treatment with aspirin and clopidogrel versus empiric treatment with aspirin and ticagrelor, versus genotype-guided therapy for either 21 or 30 days. Effect ratios were obtained from the literature, and incidence rates and costs were obtained from the national data published by the Singapore Ministry of Health. The primary endpoints were the incremental cost-effectiveness ratios (ICERs). RESULTS: Empiric treatment with aspirin and ticagrelor was the most cost-effective treatment. Genotype-guided therapy was more cost-effective than empiric aspirin and clopidogrel if the LOF was above 48%. Empiric ticagrelor and aspirin was cost saving when compared to genotype-guided therapy. Results in models of dual antiplatelet therapy for 30 days were similar. CONCLUSION: This study suggests that in patients with minor stroke and TIA planned for dual antiplatelet regimens, empiric ticagrelor and aspirin is the most cost-effective treatment regimen. If ticagrelor is not available, genotype-guided therapy is the most cost-effective treatment regimen if the LOF prevalence in the population is more than 48%.