Browsing by Subject "stroke"

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Open Access
Cognitive Function: Is There More to Anticoagulation in Atrial Fibrillation Than Stroke?
(J Am Heart Assoc, 2015-08-03) Cao, Lin; Pokorney, Sean D; Hayden, Kathleen; Welsh-Bohmer, Kathleen; Newby, L Kristin
Open Access
Contemporary trends and predictors of postacute service use and routine discharge home after stroke.
(J Am Heart Assoc, 2015-02-23) Prvu Bettger, Janet; McCoy, Lisa; Smith, Eric E; Fonarow, Gregg C; Schwamm, Lee H; Peterson, Eric D
BACKGROUND: Returning home after the hospital is a primary aim for healthcare; however, additional postacute care (PAC) services are sometimes necessary for returning stroke patients to their pre-event status. Recent trends in hospital discharge disposition specifying PAC use have not been examined across age groups or health insurance types. METHODS AND RESULTS: We examined trends in discharge to inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home with home health (HH), and home without services for 849 780 patients ≥18 years of age with ischemic or hemorrhagic stroke at 1687 hospitals participating in Get With The Guidelines-Stroke. Multivariable analysis was used to identify factors associated with discharge to any PAC (IRF, SNF, or HH) versus discharge home without services. From 2003 to 2011, there was a 2.1% increase (unadjusted P=0.001) in PAC use after a stroke hospitalization. Change was greatest in SNF use, an 8.3% decrease over the period. IRF and HH increased 6.9% and 3.6%, respectively. The 2 strongest clinical predictors of PAC use after acute care were patients not ambulating on the second day of their hospital stay (ambulation odds ratio [OR], 3.03; 95% confidence interval [CI], 2.86 to 3.23) and those who failed a dysphagia screen or had an order restricting oral intake (OR, 2.48; 95% CI, 2.37 to 2.59). CONCLUSIONS: Four in 10 stroke patients are discharged home without services. Although little has changed overall in PAC use since 2003, further research is needed to explain the shift in service use by type and its effect on outcomes.
Open Access
Effects of Low-Frequency Repetitive Transcranial Magnetic Stimulation on Language Recovery in Poststroke Survivors With Aphasia: An Updated Meta-analysis.
(Neurorehabilitation and neural repair, 2021-05-25) Hong, Zhongqiu; Zheng, Haiqing; Luo, Jing; Yin, Mingyu; Ai, Yinan; Deng, Baomei; Feng, Wuwei; Hu, Xiquan
The effects of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) on treating poststroke aphasia (PSA) remain inconclusive. We aimed to evaluate the efficacy and safety of LF-rTMS on language function poststroke and determine potential factors that may affect treatment effects. Electronic databases, including MEDLINE, EMBASE, and Cochrane Library were searched to identify relevant randomized controlled trials (RCTs) concerning the effects of LF-rTMS on language performance poststroke. We adopted fixed- and random-effects models to estimate intervention effects, which were represented by the Hedges' g and 95% CIs. Subgroup analyses regarding several factors potentially influencing the effects of LF-rTMS on language recovery were also conducted. A total of 14 RCTs involving 374 participants were included in the meta-analysis. The pooled analysis showed the positive and significant effects of LF-rTMS on language function, both short-term (Hedges' g = 0.65; P < .05) and long-term (Hedges' g = 0.46; P < .05). Subgroup analyses demonstrated that LF-rTMS for 20 minutes per day over 10 days yielded the largest effect size (Hedges' g = 1.02; P < .05) and that LF-rTMS significantly improved language performance in the chronic stage after stroke (Hedges' g = 0.55; P < .05). Patients with different native languages might have diverse responses to LF-rTMS treatment efficacy. Additionally, there were significant improvements in language subtests, including naming, repetition, comprehension, and writing. Overall, this updated meta-analysis demonstrated that LF-rTMS has significant positive effects on PSA, with moderate treatment effects. It provides additional evidence to support LF-rTMS as a promising complementary therapy to promote language recovery in PSA.
Open Access
Egg Consumption and Risk of Total and Cause-Specific Mortality: An Individual-Based Cohort Study and Pooling Prospective Studies on Behalf of the Lipid and Blood Pressure Meta-analysis Collaboration (LBPMC) Group.
(Journal of the American College of Nutrition, 2019-06-07) Mazidi, Mohsen; Katsiki, Niki; Mikhailidis, Dimitri P; Pencina, Michael J; Banach, Maciej
The associations of egg consumption with total, coronary heart disease (CHD), and stroke mortality are poorly understood. We prospectively evaluated the link between total, CHD, and stroke mortality with egg consumption using a randomly selected sample of U.S. adults. Next we validated these results within a meta-analysis and systematic review of all available prospective results. We assessed the mean of cardiometabolic risk factors across the intake of eggs. We made the analysis based on data from the National Health and Nutrition Examination Surveys (NHANES; 1999-2010). In NHANES, vital status through December 31, 2011, was ascertained. Cox proportional hazard regression models were used to relate baseline egg consumption with all-cause and cause-specific mortality. PubMed, Scopus, Web of Science, and Google Scholar databases were also searched (up to December 2017). The DerSimonian-Laird method and generic inverse variance methods were used for quantitative data synthesis. Overall, 23,524 participants from NHANES were included (mean age of 47.7 years; 48.7% were men). Across increasing the intake of eggs, adjusted mean levels of cardiometabolic risk factors worsened. Adjusted logistic regression showed that participants in the highest category of egg intake had a greater risk of diabetes (T2DM; 30%) and hypertension (HTN; 48%). With regard to total and CHD mortality, multivariable Cox regression in a fully adjusted model showed no link in males and females. In males, egg intake had a reverse (66%) association with stroke mortality, while this link was not significant among females. The results of pooling data from published prospective studies also showed no link between CHD and total mortality with egg consumption, whereas we observed a reverse (28%) association between egg intake and stroke mortality. These findings were robust after sensitivity analysis. According to our findings, egg intake had no association with CHD and total mortality, whereas was associated with lower risk of mortality from stroke. Egg consumption was associated with T2DM, HTN, C-reactive protein, and markers of glucose/insulin homeostasis. If confirmed in clinical trials (causation), this information may have applications for population-wide health measures. Key teaching points No link between total and CHD mortality with eggs intake in males and females. In males, egg intake had a reverse association with stroke mortality, while this link was not significant among females. The results of pooling data from published prospective studies also showed no link between CHD and total mortality with egg consumption, whereas we observed a reverse association between egg intake and stroke mortality.
Open Access
Estimating costs and benefits of stroke management: A population-based simulation model
(Journal of the Operational Research Society, 2020-01-01) Bayer, S; Eom, K; Sivapragasam, N; Silva, DAD; Choon, G; Koh, H; Tan, KB; Ansah, JP; Matchar, DB
The paper demonstrates how a system dynamics approach can support strategic planning of health care services and can in particular help to balance cost-effectiveness considerations with budget impact considerations when assessing a comprehensive package of stroke care interventions in Singapore. A population-level system dynamics model is used to investigate 12 intervention scenarios based on six stroke interventions (a public information campaign, thrombolysis, endovascular therapy, acute stroke unit (ASU), out-of-hospital rehabilitation, and secondary prevention). Primary outcomes included cumulative discounted costs and quality-adjusted life years (QALYs) gained, as well as cumulative net monetary benefit by 2030. All intervention scenarios result in an increase in net monetary benefit by 2030; much of these gains were realized through improved post-acute care. Findings highlight the importance of coordination of care, and affirms the economic value of current stroke interventions.
Open Access
Implementation of regional Acute Stroke Care Map increases thrombolysis rates for acute ischaemic stroke in Chinese urban area in only 3 months.
(Stroke and vascular neurology, 2020-09-24) Sui, Yi; Luo, Jianfeng; Dong, Chunyao; Zheng, Liqiang; Zhao, Weijin; Zhang, Yao; Xian, Ying; Zheng, Huaguang; Yan, Bernard; Parsons, Mark; Ren, Li; Xiao, Ying; Zhu, Haoyue; Ren, Lijie; Fang, Qi; Yang, Yi; Liu, Weidong; Xu, Bing
BACKGROUND:The rate of intravenous thrombolysis for acute ischaemic stroke remains low in China. We investigated whether the implementation of a citywide Acute Stroke Care Map (ASCaM) is associated with an improvement of acute stroke care quality in a Chinese urban area. METHODS:The ASCaM comprises 10 improvement strategies and has been implemented through a network consisting of 20 tertiary hospitals. We identified 7827 patients with ischaemic stroke admitted from April to October 2017, and 506 patients underwent thrombolysis were finally included for analysis. RESULTS:Compared with 'pre-ASCaM period', we observed an increased rate of administration of tissue plasminogen activator within 4.5 hours (65.4% vs 54.5%; adjusted OR, 1.724; 95% CI 1.21 to 2.45; p=0.003) during 'ASCaM period'. In multivariate analysis models, 'ASCaM period' was associated with a significant reduction in onset-to-door time (114.1±55.7 vs 135.7±58.4 min, p=0.0002) and onset-to-needle time (ONT) (169.2±58.1 vs 195.6±59.3 min, p<0.0001). Yet no change was found in door-to-needle time. Clinical outcomes such as symptomatic intracranial haemorrhage, favourable functional outcome (modified Rankin Scale ≤2) and in-hospital mortality remained unchanged. CONCLUSION:The implementation of ASCaM was significantly associated with increased rates of intravenous thrombolysis and shorter ONT. The ASCaM may, in proof-of-principle, serve as a model to reduce treatment delay and increase thrombolysis rates in Chinese urban areas and possibly other highly populated Asian regions.
Open Access
Intensity of Lipid Lowering With Statin Therapy in Patients With Cerebrovascular Disease Versus Coronary Artery Disease: Insights from the PALM Registry.
(Journal of the American Heart Association, 2019-10) Xian, Ying; Navar, Ann Marie; Li, Shuang; Li, Zhuokai; Robinson, Jennifer; Virani, Salim S; Louie, Michael J; Koren, Andrew; Goldberg, Anne; Roger, Veronique L; Wilson, Peter WF; Peterson, Eric D; Wang, Tracy Y
Background Current treatment guidelines strongly recommend statin therapy for secondary prevention. However, it remains unclear whether patients' perceptions of cardiovascular risk, beliefs on cholesterol, or the intensity of prescribed statin therapy differs for patients with coronary artery disease (CAD) versus cerebrovascular disease (CeVD) versus both CAD and CeVD (CAD&CeVD). Methods and Results The PALM (Patient and Provider Assessment of Lipid Management) registry collected data on statin use, intensity, and core laboratory low-density lipoprotein cholesterol levels for 3232 secondary prevention patients treated at 133 US clinics. Among individuals with CeVD only (n=403), CAD only (n=2202), and CeVD&CAD (n=627), no significant differences were observed in patient-perceived cardiovascular disease risk, beliefs on cholesterol lowering, or perceived effectiveness and safety of statin therapy. However, patients with CeVD only were less likely to receive any statin therapy (76.2% versus 86.2%; adjusted odds ratio 0.64, 95% CI 0.45-0.91), or guideline-recommended statin intensity (34.6% versus 50.4%; adjusted odds ratio 0.60, 95% CI 0.45-0.81) than those with CAD only. Individuals with CeVD only were also less likely to achieve low-density lipoprotein cholesterol <100 mg/dL (59.2% versus 69.7%; adjusted odds ratio 0.79, 95% CI 0.64-0.99) than individuals with CAD alone. There were no significant differences in the use of any statin therapy or guideline-recommended statin intensity between individuals with CAD&CeVD and those with CAD only. Conclusions Despite lack of significant differences in patient-perceived cardiovascular risk or statin beliefs, patients with CeVD were significantly less likely to receive higher intensity statin or achieve low-density lipoprotein cholesterol <100 mg/dL than those with CAD only.
Open Access
Major themes for 2013 in cardiothoracic and vascular anaesthesia and intensive care.
(Heart, lung and vessels, 2014-01) Gutsche, JT; Riha, H; Patel, P; Sahota, GS; Valentine, E; Ghadimi, K; Silvay, G; Augoustides, JGT
There has been significant progress throughout 2013 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the medical and interventional management of atrial fibrillation. The medical advances include robust clinical risk scoring systems, novel oral anticoagulants, and growing clinical experience with a new antiarrhythmic agent. The interventional advances include left atrial appendage occlusion for stroke reduction, generalization of ablation techniques in cardiac surgery, thoracoscopic ablation techniques, and the emergence of the hybrid ablation procedure. Recent European guidelines have defined the organization and practice of two subspecialties, namely general thoracic surgery and grown-up congenital heart disease. The pivotal role of an effective multidisciplinary milieu is a central theme in both these clinical arenas. The anaesthesia team features prominently in each of these recent guidelines aimed at harmonizing delivery of perioperative care for these patient cohorts across Europe. Web-Enabled Democracy-Based Consensus is a system that allows physicians worldwide to agree or disagree with statements and expert consensus meetings and has the potential to increase the understanding of global practice and to help clinicians better define research priorities. This "Democratic based medicine", firstly used to assess the interventions that might reduce perioperative mortality has been applied in 2013 to the setting of critically ill patient with acute kidney injury. These advances in 2013 will likely further improve perioperative outcomes for our patients.
Open Access
Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke.
(J Am Heart Assoc, 2012-08) Lin, Cheryl B; Peterson, Eric D; Smith, Eric E; Saver, Jeffrey L; Liang, Li; Xian, Ying; Olson, Daiwai M; Shah, Bimal R; Hernandez, Adrian F; Schwamm, Lee H; Fonarow, Gregg C
BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and peripheral vascular disease. Prenotification was less likely for black patients than for white patients (adjusted odds ratio 0.94, 95% confidence interval 0.92-0.97, P<0.0001). Hospital factors associated with greater EMS prenotification use were absence of academic affiliation, higher annual volume of tissue plasminogen activator administration, and geographic location outside the Northeast. Temporal improvements in prenotification rates showed a modest general increase, from 58.0% in 2003 to 67.3% in 2011 (P temporal trend <0.0001). CONCLUSIONS#ENTITYSTARTX02014;: EMS hospital prenotification is guideline recommended, yet among patients transported to Get With The Guidelines-Stroke hospitals it is not provided for 1 in 3 EMS-arriving patients with acute ischemic stroke and varies substantially by hospital, state, and region. These results support the need for enhanced implementation of stroke systems of care. (J Am Heart Assoc. 2012;1:e002345 doi: 10.1161/JAHA.112.002345.).
Open Access
Perception Versus Actual Performance in Timely Tissue Plasminogen Activation Administration in the Management of Acute Ischemic Stroke.
(J Am Heart Assoc, 2015-07-22) Lin, Cheryl B; Cox, Margueritte; Olson, DaiWai M; Britz, Gavin W; Constable, Mark; Fonarow, Gregg C; Schwamm, Lee; Peterson, Eric D; Shah, Bimal R
BACKGROUND: Timely thrombolytic therapy can improve stroke outcomes. Nevertheless, the ability of US hospitals to meet guidelines for intravenous tissue plasminogen activator (tPA) remains suboptimal. What is unclear is whether hospitals accurately perceive their rate of tPA "door-to-needle" (DTN) time within 60 minutes and how DTN rates compare across different hospitals. METHODS AND RESULTS: DTN performance was defined by the percentage of treated patients who received tPA within 60 minutes of arrival. Telephone surveys were obtained from staff at 141 Get With The Guidelines hospitals, representing top, middle, and low DTN performance. Less than one-third (29.1%) of staff accurately identified their DTN performance. Among middle- and low-performing hospitals (n=92), 56 sites (60.9%) overestimated their performance; 42% of middle performers and 85% of low performers overestimated their performance. Sites that overestimated tended to have lower annual volumes of tPA administration (median 8.4 patients [25th to 75th percentile 5.9 to 11.8] versus 10.2 patients [25th to 75th percentile 8.2 to 17.3], P=0.047), smaller percentages of eligible patients receiving tPA (84.7% versus 89.8%, P=0.008), and smaller percentages of DTN ≤60 minutes among treated patients (10.6% versus 16.6%, P=0.002). CONCLUSIONS: Hospitals often overestimate their ability to deliver timely tPA to treated patients. Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.
Open Access
Recent Myocardial Infarction is Associated With Increased Risk in Older Adults With Acute Ischemic Stroke Receiving Thrombolytic Therapy.
(Journal of the American Heart Association, 2019-08) Inohara, Taku; Liang, Li; Kosinski, Andrzej S; Smith, Eric E; Schwamm, Lee H; Hernandez, Adrian F; Bhatt, Deepak L; Fonarow, Gregg C; Peterson, Eric D; Xian, Ying
Background Intravenous recombinant tissue-type plasminogen activator (rtPA) remains the only medical therapy to improve outcomes for acute ischemic stroke (AIS), but the safety of rtPA in AIS patients with a history of recent myocardial infarction (MI) remains controversial. Methods and Results We sought to determine whether the presence of recent MI would alter the risk of mortality and rtPA-related complications. Multivariate logistic regression models were used to compare in-hospital outcomes between rtPA-treated AIS patients with recent MI within 3 months and those with no history of MI from the Get With The Guidelines-Stroke hospitals between February 2009 and December 2015. Among 40 396 AIS patients aged ≥65 years treated with rtPA, 241 (0.6%) had recent MI, of which 19.5% were ST-segment-elevation myocardial infarction. Patients with recent MI had more severe stroke than those without (median National Institutes of Health Stroke Scale [interquartile range]: 13.0 [7.0-20.0] versus 11.0 [6.0-18.0]). Recent MI was associated with an increased risk of mortality compared with no history of MI (17.4% versus 9.0%; adjusted odds ratio 1.60 [95% CI, 1.10-2.33]; P=0.014), but no statistically significant differences in rtPA-related complications (13.5% versus 9.4%; adjusted odds ratio 1.28 [0.88-1.86]; P=0.19). Recent ST-segment-elevation myocardial infarction was associated with higher risk of death and rtPA-related complications, but non-ST-segment-elevation myocardial infarction was not. Conclusions Among older AIS patients treated with rtPA, recent MI was associated with an increased risk of in-hospital mortality. Further investigations are necessary to determine whether the benefit of rtPA outweighs its risk among AIS patients with recent MI.
Open Access
Strategic planning to reduce the burden of stroke among veterans: using simulation modeling to inform decision making.
(Stroke, 2014-07) Lich, Kristen Hassmiller; Tian, Yuan; Beadles, Christopher A; Williams, Linda S; Bravata, Dawn M; Cheng, Eric M; Bosworth, Hayden B; Homer, Jack B; Matchar, David B
BACKGROUND AND PURPOSE: Reducing the burden of stroke is a priority for the Veterans Affairs Health System, reflected by the creation of the Veterans Affairs Stroke Quality Enhancement Research Initiative. To inform the initiative's strategic planning, we estimated the relative population-level impact and efficiency of distinct approaches to improving stroke care in the US Veteran population to inform policy and practice. METHODS: A System Dynamics stroke model of the Veteran population was constructed to evaluate the relative impact of 15 intervention scenarios including both broad and targeted primary and secondary prevention and acute care/rehabilitation on cumulative (20 years) outcomes including quality-adjusted life years (QALYs) gained, strokes prevented, stroke fatalities prevented, and the number-needed-to-treat per QALY gained. RESULTS: At the population level, a broad hypertension control effort yielded the largest increase in QALYs (35,517), followed by targeted prevention addressing hypertension and anticoagulation among Veterans with prior cardiovascular disease (27,856) and hypertension control among diabetics (23,100). Adjusting QALYs gained by the number of Veterans needed to treat, thrombolytic therapy with tissue-type plasminogen activator was most efficient, needing 3.1 Veterans to be treated per QALY gained. This was followed by rehabilitation (3.9) and targeted prevention addressing hypertension and anticoagulation among those with prior cardiovascular disease (5.1). Probabilistic sensitivity analysis showed that the ranking of interventions was robust to uncertainty in input parameter values. CONCLUSIONS: Prevention strategies tend to have larger population impacts, though interventions targeting specific high-risk groups tend to be more efficient in terms of number-needed-to-treat per QALY gained.
Open Access
Whole Brain White Matter Microstructure and Upper Limb Function: Longitudinal Changes in Fractional Anisotropy and Axial Diffusivity in Post-Stroke Patients.
(Journal of central nervous system disease, 2019-01) Oey, Nicodemus Edrick; Samuel, Geoffrey Sithamparapillai; Lim, Joseph Kai Wei; VanDongen, Antonius Mj; Ng, Yee Sien; Zhou, Juan
Background:Diffusion tensor imaging (DTI) magnetic resonance imaging (MRI) measuring fractional anisotropy (FA) and axial diffusivity (AD) may be a useful biomarker for monitoring changes in white matter after stroke, but its associations with upper-limb motor recovery have not been well studied. We aim to describe changes in the whole-brain FA and AD in five post-stroke patients in relation to kinematic measures of elbow flexion to better understand the relationship between FA and AD changes and clinico-kinematic measures of upper limb motor recovery. Methods:We performed DTI MRI at two timepoints during the acute phase of stroke, measuring FA and AD across 48 different white matter tract regions in the brains of five hemiparetic patients with infarcts in the cortex, pons, basal ganglia, thalamus, and corona radiata. We tracked the progress of these patients using clinical Fugl-Meyer Assessments and kinematic measures of elbow flexion at the acute phase within 14 (mean: 9.4 ± 2.49) days of stroke symptom onset and at a follow-up appointment 2 weeks later (mean: 16 ± 1.54) days. Results:Changes in FA and AD in 48 brain regions occurring during stroke rehabilitation are described in relation to motor recovery. In this case series, one patient with a hemipontine infarct showed an increase in FA of the ipsilateral and contralateral corticospinal tract, whereas other patients with lesions involving the corona radiata and middle cerebral artery showed widespread decreases in perilesional FA. On the whole, FA and AD seemed to behave inversely to each other. Conclusions:This case series describes longitudinal changes in perilesional and remote FA and AD in relation to kinematic parameters of elbow flexion at the subacute post-stroke period. Although studies with larger sample sizes are needed, our findings indicate that longitudinally measured changes in DTI-based measurements of white matter microstructural integrity may aid in the prognostication of patients affected by motor stroke.