Brain Ischemia

The U.S. Preventive Services Task Force continues to recommend against screening for asymptomatic carotid stenosis finding that it causes more harm than good. That includes not listening for carotid bruits in asymptomatic patients. James W. Mold, MD, MPH

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Importance: Carotid artery stenosis is atherosclerotic disease that affects extracranial carotid arteries. Asymptomatic carotid artery stenosis refers to stenosis in persons without a history of ischemic stroke, transient ischemic attack, or other neurologic symptoms referable to the carotid arteries. The prevalence of asymptomatic carotid artery stenosis is low in the general population but increases with age.

Objective: To determine if its 2014 recommendation should be reaffirmed, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence review. The reaffirmation update focused on the targeted key questions on the potential benefits and harms of screening and interventions, including revascularization procedures designed to improve carotid artery blood flow, in persons with asymptomatic carotid artery stenosis.

Population: This recommendation statement applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms referable to the carotid arteries.

Evidence assessment: The USPSTF found no new substantial evidence that could change its recommendation and therefore concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits.

Recommendation: The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (

Author/s:

US Preventive Services Task Force

Colchicine in Patients with Chronic Coronary Disease

Brian Desmarais — Sat, 07 Nov 2020 22:20:46 +0000

Date Added:

November 7, 2020

Journal/Publication:

New England Journal of Medicine

Publication Date:

November 5, 2020

URL:

Colchicine in Patients with Chronic Coronary Disease

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2021372

MeSH

Heart Diseases

Myocardial Ischemia

coronary artery disease

myocardial infarction

In this RCT involving patients with chronic coronary artery disease, 0.5mg of colchicine daily reduce the risk of a composite endpoint of cardiovascular death, myocardial infarction, ischemic stroke, or ischemia-driven coronary revascularization. James W. Mold, MD, MPH

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Abstract

Background: Evidence from a recent trial has shown that the antiinflammatory effects of colchicine reduce the risk of cardiovascular events in patients with recent myocardial infarction, but evidence of such a risk reduction in patients with chronic coronary disease is limited.

Methods: In a randomized, controlled, double-blind trial, we assigned patients with chronic coronary disease to receive 0.5 mg of colchicine once daily or matching placebo. The primary end point was a composite of cardiovascular death, spontaneous (nonprocedural) myocardial infarction, ischemic stroke, or ischemia-driven coronary revascularization. The key secondary end point was a composite of cardiovascular death, spontaneous myocardial infarction, or ischemic stroke.

Results: A total of 5522 patients underwent randomization; 2762 were assigned to the colchicine group and 2760 to the placebo group. The median duration of follow-up was 28.6 months. A primary end-point event occurred in 187 patients (6.8%) in the colchicine group and in 264 patients (9.6%) in the placebo group (incidence, 2.5 vs. 3.6 events per 100 person-years; hazard ratio, 0.69; 95% confidence interval [CI], 0.57 to 0.83; P<0.001). A key secondary end-point event occurred in 115 patients (4.2%) in the colchicine group and in 157 patients (5.7%) in the placebo group (incidence, 1.5 vs. 2.1 events per 100 person-years; hazard ratio, 0.72; 95% CI, 0.57 to 0.92; P = 0.007). The incidence rates of spontaneous myocardial infarction or ischemia-driven coronary revascularization (composite end point), cardiovascular death or spontaneous myocardial infarction (composite end point), ischemia-driven coronary revascularization, and spontaneous myocardial infarction were also significantly lower with colchicine than with placebo. The incidence of death from noncardiovascular causes was higher in the colchicine group than in the placebo group (incidence, 0.7 vs. 0.5 events per 100 person-years; hazard ratio, 1.51; 95% CI, 0.99 to 2.31).

Conclusions: In a randomized trial involving patients with chronic coronary disease, the risk of cardiovascular events was significantly lower among those who received 0.5 mg of colchicine once daily than among those who received placebo. (Funded by the National Health Medical Research Council of Australia and others; LoDoCo2 Australian New Zealand Clinical Trials Registry number, ACTRN12614000093684.).

Author/s:

LoDoCo2 Trial Investigators

Aspirin for Primary Atherosclerotic Cardiovascular Disease Prevention as Baseline Risk Increases: A Meta-Regression Analysis

John Bayhi — Thu, 21 May 2020 16:39:36 +0000

Date Added:

May 21, 2020

Journal/Publication:

The American Journal of Medicine

Publisher:

Elsevier Inc

Publication Date:

May 20, 2020

Volume:

Article in Press

URL:

Aspirin for Primary Atherosclerotic Cardiovascular Disease Prevention as Baseline Risk Increases: A Meta-Regression Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.amjmed.2020.04.028

Keywords

aspirin

primary prevention

Atherosclerotic Cardiovascular Disease

myocardial infarction

MeSH

cardiovascular diseases

Brain Ischemia

follow-up studies

myocardial infarction

This analysis of 12 RCTs involving almost 1 million patients found that low-dose aspirin prevents major cardiovascular events (RRReduction 14%; ARR/1000 patient years 0.06%) but increases major bleeding events (RRIncrease 40%; ARR/1000 patient years 0.1%) across all levels of baseline risk. The researchers concluded that the absolute risk reduction and the risk: benefit ratio suggest that we should probably not prescribe low-dose aspirin for primary prevention even if the baseline risk of CV events is high and the risk of bleeding is low. James W. Mold, MD, MPH

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Background

Aspirin is often prescribed for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) however, recent randomized trials (RCTs) have challenged this practice. Despite this, aspirin is commonly recommended for high risk primary prevention. We tested the hypothesis that aspirin is more efficacious for the primary prevention of ASCVD, as the baseline risk increases.

Methods

RCTs that compared aspirin to control for primary prevention and evaluated ASCVD (composite of myocardial infarction and ischemic stroke) and major bleeding were included. Rate ratios (RR) and 95% confidence intervals (CI) were calculated. A regression analysis was performed using the ASCVD event rate in the control arm of each RCT as the moderator.

Results

Twelve RCTs were identified with 963,829 patient years of follow-up. Aspirin was associated with a reduction in ASCVD (4.7 versus 5.3 events per 1,000 patient years; RR 0.86; 95% CI 0.79-0.92). There was increased major bleeding among aspirin users (2.5 versus 1.8 events per 1000 patient years, RR 1.41 95% CI, 1.29-1.54). Regression analysis found no relationship between the log rate ratio of ASCVD or major bleeding and incidence of ASCVD in the control arm of each RCT.

Conclusion

Aspirin is associated with a reduction in ASCVD when used for primary prevention; however, it is unlikely to be clinically significant given the increase in bleeding. More importantly, aspirin's treatment effect does not increase as ASCVD risk increases as many hypothesize. There is no suggestion from this data that use of aspirin for higher risk primary prevention patients is beneficial.

Author/s:

Nudy, M, Cooper, J, Ghahramani, M, Ruzieh, M, Mandrola, J, Foy, AJ

Management of Patients With Acute Ischemic Stroke

John Bayhi — Mon, 22 Jul 2019 14:13:28 +0000

Date Added:

July 22, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

July 18, 2019

URL:

Management of Patients With Acute Ischemic Stroke

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2019.10436

Keywords

stroke

ischemia

stents

PMID (1):

31318383

MeSH

This is a recent updated version of the ACC/AHA Guidelines regarding management of acute ischemic stroke. For outpatient clinicians the most important point is that patients benefit from antithrombotic measures up to 4.5 hours after the onset of symptoms. James W. Mold, MD, MPH

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Guideline title 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Release date January 24, 2018

Prior version 2013

Developer American Heart Association (AHA)/American Stroke Association (ASA)

Funding source AHA/ASA

Target population Adult patients with acute arterial ischemic stroke

Major recommendations

Regional systems of stroke care should be developed that include health care facilities providing initial emergency care and those capable of endovascular stroke treatment, to which rapid transport can be arranged when appropriate (high-quality evidence; strong recommendation).
Intravenous alteplase is recommended for patients meeting detailed eligibility requirements within 3 hours of ischemic stroke onset (high-quality evidence; strong recommendation) and between 3 and 4.5 hours of ischemic stroke onset (moderate-quality evidence; strong recommendation).
Mechanical thrombectomy with a stent retriever is recommended for patients with a causative occlusion of the internal carotid artery or proximal middle cerebral artery with at least moderately severe presenting stroke deficits (National Institutes of Health Stroke Scale [NIHSS] score ≥6) and absence of evidence of widespread established infarction on brain imaging, when endovascular treatment can be initiated within 6 hours of symptom onset (high-quality evidence; strong recommendation).
Mechanical thrombectomy with a stent retriever is also recommended for certain acute ischemic stroke (AIS) patients presenting at later times (moderate- to high-quality evidence; strong recommendation).

Author/s:

Cifu, A.S., Brorson, J.R.