Browsing by Author "Sheth, Kevin N"

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    Anticoagulation in Acute Neurological Disease.
    (Seminars in neurology, 2021-10) Sasannejad, Cina; Sheth, Kevin N
    While anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.
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    Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes.
    (Neurology, 2016-01-12) Hwang, David Y; Dell, Cameron A; Sparks, Mary J; Watson, Tiffany D; Langefeld, Carl D; Comeau, Mary E; Rosand, Jonathan; Battey, Thomas WK; Koch, Sebastian; Perez, Mario L; James, Michael L; McFarlin, Jessica; Osborne, Jennifer L; Woo, Daniel; Kittner, Steven J; Sheth, Kevin N
    OBJECTIVE: To compare the performance of formal prognostic instruments vs subjective clinical judgment with regards to predicting functional outcome in patients with spontaneous intracerebral hemorrhage (ICH). METHODS: This prospective observational study enrolled 121 ICH patients hospitalized at 5 US tertiary care centers. Within 24 hours of each patient's admission to the hospital, one physician and one nurse on each patient's clinical team were each asked to predict the patient's modified Rankin Scale (mRS) score at 3 months and to indicate whether he or she would recommend comfort measures. The admission ICH score and FUNC score, 2 prognostic scales selected for their common use in neurologic practice, were calculated for each patient. Spearman rank correlation coefficients (r) with respect to patients' actual 3-month mRS for the physician and nursing predictions were compared against the same correlation coefficients for the ICH score and FUNC score. RESULTS: The absolute value of the correlation coefficient for physician predictions with respect to actual outcome (0.75) was higher than that of either the ICH score (0.62, p = 0.057) or the FUNC score (0.56, p = 0.01). The nursing predictions of outcome (r = 0.72) also trended towards an accuracy advantage over the ICH score (p = 0.09) and FUNC score (p = 0.03). In an analysis that excluded patients for whom comfort care was recommended, the 65 available attending physician predictions retained greater accuracy (r = 0.73) than either the ICH score (r = 0.50, p = 0.02) or the FUNC score (r = 0.42, p = 0.004). CONCLUSIONS: Early subjective clinical judgment of physicians correlates more closely with 3-month outcome after ICH than prognostic scales.
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    Hospital distance, socioeconomic status, and timely treatment of ischemic stroke.
    (Neurology, 2019-08) Ader, Jeremy; Wu, Jingjing; Fonarow, Gregg C; Smith, Eric E; Shah, Shreyansh; Xian, Ying; Bhatt, Deepak L; Schwamm, Lee H; Reeves, Mathew J; Matsouaka, Roland A; Sheth, Kevin N
    OBJECTIVE:To determine whether lower socioeconomic status (SES) and longer home to hospital driving time are associated with reductions in tissue plasminogen activator (tPA) administration and timeliness of the treatment. METHODS:We conducted a retrospective observational study using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between January 2015 and March 2017. The study included 118,683 ischemic stroke patients age ≥18 who were transported by emergency medical services to one of 1,489 US hospitals. We defined each patient's SES based on zip code median household income. We calculated the driving time between each patient's home zip code and the hospital where he or she was treated using the Google Maps Directions Application Programing Interface. The primary outcomes were tPA administration and onset-to-arrival time (OTA). Outcomes were analyzed using hierarchical multivariable logistic regression models. RESULTS:SES was not associated with OTA (p = 0.31) or tPA administration (p = 0.47), but was associated with the secondary outcomes of onset-to-treatment time (OTT) (p = 0.0160) and in-hospital mortality (p = 0.0037), with higher SES associated with shorter OTT and lower in-hospital mortality. Driving time was associated with tPA administration (p < 0.001) and OTA (p < 0.0001), with lower odds of tPA (0.83, 0.79-0.88) and longer OTA (1.30, 1.24-1.35) in patients with the longest vs shortest driving time quartiles. Lower SES quintiles were associated with slightly longer driving time quartiles (p = 0.0029), but there was no interaction between the SES and driving time for either OTA (p = 0.1145) or tPA (p = 0.6103). CONCLUSIONS:Longer driving times were associated with lower odds of tPA administration and longer OTA; however, SES did not modify these associations.
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    Temperature and Precipitation Associate With Ischemic Stroke Outcomes in the United States.
    (Journal of the American Heart Association, 2018-11) Chu, Stacy Y; Cox, Margueritte; Fonarow, Gregg C; Smith, Eric E; Schwamm, Lee; Bhatt, Deepak L; Matsouaka, Roland A; Xian, Ying; Sheth, Kevin N
    Background There is disagreement in the literature about the relationship between strokes and seasonal conditions. We sought to (1) describe seasonal patterns of stroke in the United States, and (2) determine the relationship between weather variables and stroke outcomes. Methods and Results We performed a cross-sectional study using Get With The Guidelines-Stroke data from 896 hospitals across the continental United States. We examined effects of season, climate region, and climate variables on stroke outcomes. We identified 457 638 patients admitted from 2011 to 2015 with ischemic stroke. There was a higher frequency of admissions in winter (116 862 in winter versus 113 689 in spring, 113 569 in summer, and 113 518 in fall; P<0.0001). Winter was associated with higher odds of in-hospital mortality (odds ratio [OR] 1.08 relative to spring, confidence interval [ CI ] 1.04-1.13, P=0.0004) and lower odds of discharge home ( OR 0.92, CI 0.91-0.94, P<0.0001) or independent ambulation at discharge ( OR 0.96, CI 0.94-0.98, P=0.0006). These differences were attenuated after adjusting for climate region and case mix and became inconsistent after controlling for weather variables. Temperature and precipitation were independently associated with outcome after multivariable analysis, with increases in temperature and precipitation associated with lower odds of mortality ( OR 0.95, CI 0.93-0.97, P<0.0001 and OR 0.95, CI 0.90-1.00, P=0.035, respectively). Conclusions Admissions for ischemic stroke were more frequent in the winter. Warmer and wetter weather conditions were independently associated with better outcomes. Further studies should aim to identify sensitive populations and inform public health measures aimed at resource allocation, readiness, and adaptive strategies.
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    Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage.
    (JAMA neurology, 2024-02) Sheth, Kevin N; Solomon, Nicole; Alhanti, Brooke; Messe, Steven R; Xian, Ying; Bhatt, Deepak L; Hemphill, J Claude; Frontera, Jennifer A; Chang, Raymond C; Danelich, Ilya M; Huang, Joanna; Schwamm, Lee; Smith, Eric E; Goldstein, Joshua N; Mac Grory, Brian; Fonarow, Gregg C; Saver, Jeffrey L

    Importance

    Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice.

    Objective

    To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions.

    Design, setting, and participants

    This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023.

    Exposures

    Anticoagulation-associated ICH.

    Main outcomes and measures

    DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined.

    Results

    Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity.

    Conclusions and relevance

    In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.