stroke

Atrial Fibrillation* / diagnosis

PMID (1):

39680399

MeSH

catheter ablation

Anticoagulants* / therapeutic use

Stroke / etiology

Stroke / prevention & control

An evidence-based review of what we know and think we know about atrial fibrillation. James W. Mold, MD, MPH.

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Importance: In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations: Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and relevance: AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Author/s:

Darae Ko, Mina K Chung, Peter T Evans, Emelia J Benjamin, Robert H Helm

Atrial Fibrillation: A Review

Alex Haga — Sun, 05 Jan 2025 21:39:50 +0000

Date Added:

January 5, 2025

Journal/Publication:

JAMA

Publication Date:

December 16, 2024

URL:

Atrial Fibrillation: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.22451

Keywords

heart failure

PMID (1):

39680399

MeSH

Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People

A review of current knowledge and opinion regarding the causes and management of atrial fibrillation. James W. Mold, MD, MPH

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Author/s:

Darae Ko, Mina K Chung, Peter T Evans, Emelia J Benjamin, Robert H Helm

Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People

Rowan Hutchins — Sun, 17 Sep 2023 05:00:00 +0000

Date Added:

September 17, 2023

Journal/Publication:

JAMA Netw Open

Publisher:

American Medical Association

Publication Date:

July 26, 2023

Issue:

Volume:

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2023.25803

Keywords

PMID (1):

37494038

MeSH

aspirin / adverse effects

Cerebral Hemorrhage / chemically induced

Intracranial Hemorrhages / chemically induced

Stroke* / drug therapy

RPR Commentary: Low dose aspirin probably has little benefit for stroke prevention and significant risk of intracranial bleed in older people, particularly if they are at risk for falls or other head trauma. In this study, the risk of heart attack with and without aspirin was not examined. James W. Mold, MD, MPH

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Importance Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not been established in older individuals.

Objective To establish the risks of ischemic stroke and intracranial bleeding among healthy older people receiving daily low-dose aspirin.

Design, Setting, and Participants This secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, double-blind, placebo-controlled trial of daily low-dose aspirin was conducted among community-dwelling people living in Australia or the US. Participants were older adults free of symptomatic cardiovascular disease. Recruitment took place between 2010 and 2014, and participants were followed up for a median (IQR) of 4.7 (3.6-5.7) years. This analysis was completed from August 2021 to March 2023.

Interventions Daily 100-mg enteric-coated aspirin or matching placebo.

Main Outcomes and Measures Stroke and stroke etiology were predetermined secondary outcomes and are presented with a focus on prevention of initial stroke or intracranial bleeding event. Outcomes were assessed by review of medical records.

Results Among 19 114 older adults (10 782 females [56.4%]; median [IQR] age, 74 [71.6-77.7] years), 9525 individuals received aspirin and 9589 individuals received placebo. Aspirin did not produce a statistically significant reduction in the incidence of ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.71-1.11). However, a statistically significant increase in intracranial bleeding was observed among individuals assigned to aspirin (108 individuals [1.1%]) compared with those receiving placebo (79 individuals [0.8%]; HR, 1.38; 95% CI, 1.03-1.84). This occurred by an increase in a combination of subdural, extradural, and subarachnoid bleeding with aspirin compared with placebo (59 individuals [0.6%] vs 41 individuals [0.4%]; HR, 1.45; 95% CI, 0.98-2.16). Hemorrhagic stroke was recorded in 49 individuals (0.5%) assigned to aspirin compared with 37 individuals (0.4%) in the placebo group (HR, 1.33; 95% CI, 0.87-2.04).

Conclusions and Relevance This study found a significant increase in intracranial bleeding with daily low-dose aspirin but no significant reduction of ischemic stroke. These findings may have particular relevance to older individuals prone to developing intracranial bleeding after head trauma.

Author/s:

Cloud, Geoffrey, Williamson, Jeff D., Le Thi Phuong Thao

Bempedoic Acid for Primary Prevention of Cardiovascular Events in Statin-Intolerant Patients

Aubrey Delammermore — Sat, 15 Jul 2023 05:00:00 +0000

Date Added:

July 15, 2023

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

July 11, 2023

Issue:

Volume:

330

Pages:

131-140

URL:

Bempedoic Acid for Primary Prevention of Cardiovascular Events in Statin-Intolerant Patients

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2023.9696

Keywords

Cardiovascular Diseases

statin-intolerant patients

drug therapy

bempedoic acid

PMID (1):

37354546

MeSH

Cardiovascular Diseases* / chemically induced

Hydroxymethylglutaryl-CoA Reductase Inhibitors* / adverse effects

Myocardial Infarction* / mortality

Stroke* / drug therapy

primary prevention

In this large RCT of patients at very high risk of CV events but no history of events, bempedoic acid 180mg daily reduced risk of MI, cardiovascular mortality, and all-cause mortality by 0.8%, 1.3%, and 1.6% (absolute risk reductions) respectively over a period of 39 months.

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Importance: The effects of bempedoic acid on cardiovascular outcomes in statin-intolerant patients without a prior cardiovascular event (primary prevention) have not been fully described.

Objective: To determine the effects of bempedoic acid on cardiovascular outcomes in primary prevention patients.

Design, setting, and participants: This masked, randomized clinical trial enrolled 13 970 statin-intolerant patients (enrollment December 2016 to August 2019 at 1250 centers in 32 countries), including 4206 primary prevention patients.

Interventions: Participants were randomized to oral bempedoic acid, 180 mg daily (n = 2100), or matching placebo (n = 2106).

Main outcome measures: The primary efficacy measure was the time from randomization to the first occurrence of any component of a composite of cardiovascular death, nonfatal myocardial infarction (MI), nonfatal stroke, or coronary revascularization.

Results: Mean participant age was 68 years, 59% were female, and 66% had diabetes. From a mean baseline of 142.2 mg/dL, compared with placebo, bempedoic acid reduced low-density lipoprotein cholesterol levels by 30.2 mg/dL (21.3%) and high-sensitivity C-reactive protein levels by 0.56 mg/L (21.5%), from a median baseline of 2.4 mg/L. Follow-up for a median of 39.9 months was associated with a significant risk reduction for the primary end point (111 events [5.3%] vs 161 events [7.6%]; adjusted hazard ratio [HR], 0.70 [95% CI, 0.55-0.89]; P = .002) and key secondary end points, including the composite of cardiovascular death, MI, or stroke (83 events [4.0%] vs 134 events [6.4%]; HR, 0.64 [95% CI, 0.48-0.84]; P < .001); MI (29 events [1.4%] vs 47 events [2.2%]; HR, 0.61 [95% CI, 0.39-0.98]); cardiovascular death (37 events [1.8%] vs 65 events [3.1%]; HR, 0.61 [95% CI, 0.41-0.92]); and all-cause mortality (75 events [3.6%] vs 109 events [5.2%]; HR, 0.73 [95% CI, 0.54-0.98]). There was no significant effect on stroke or coronary revascularization. Adverse effects with bempedoic acid included a higher incidence of gout (2.6% vs 2.0%), cholelithiasis (2.5% vs 1.1%), and increases in serum creatinine, uric acid, and hepatic enzyme levels.

Conclusions: In a subgroup of high-risk primary prevention patients, bempedoic acid treatment was associated with reduced major cardiovascular events.

Author/s:

Nissen, S. E., Menon, V., Nicholls, S. J., Brennan, D., Laffin, L., Ridker, P., Ray, K. K., Mason, D., Kastelein, J. J. P., Cho, L., Libby, P., Li, N., Foody, J., Louie, M. J., Lincoff, A. M.

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Aubrey Delammermore — Thu, 08 Sep 2022 05:00:00 +0000

Date Added:

September 8, 2022

Journal/Publication:

Heart

Publisher:

BMJ Publishing Group

Publication Date:

August 9, 2022

Pages:

1-8

URL:

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1136/heartjnl-2022-321332

Keywords

PMID (1):

35945000

MeSH

Randomized Controlled Trials as Topic

Odds Ratio

body mass index

Salt substitutes, when compared to use of regular salt, reduce BP, CV mortality, and all-cause mortality.

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Objectives The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results.

Methods We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups.

Results There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was −4.61 mm Hg (95% CI −6.07 to −3.14) and of diastolic blood pressure (DBP) was −1.61 mm Hg (95% CI −2.42 to −0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a −1.53 mm Hg (95% CI −3.02 to −0.03, p=0.045) greater reduction in SBP and a −0.95 mm Hg (95% CI −1.78 to −0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94).

Conclusions The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide.

Author/s:

Yin, X., Rodgers, A., Perkovic, A., Huang, L., Li, K., Yu, J., Wu, Y., Wu, J. H. Y., Marklund, M., Huffman, M. D., Miranda, J. J., Di Tanna, G. L., Labarthe, D., Elliott, P., Tian, M., Neal, B.

Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis The CASSISS Randomized Clinical Trial

Aubrey Delammermore — Thu, 11 Aug 2022 05:00:00 +0000

Date Added:

August 11, 2022

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

August 8, 2022

Issue:

Volume:

328

Pages:

URL:

Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis The CASSISS Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2022.12000

Keywords

randomized controlled trial

Multicenter Study

Treatment Outcome

Pathologic Constriction

Pathologic / complications

Stent

PMID (1):

35943472

MeSH

Constriction

Stroke* / drug therapy

Intracranial Arteriosclerosis* / therapy

Ischemic Attack

Transient* / complications

Stents / adverse effects

Platelet Aggregation Inhibitors / therapeutic use

Carotid artery angioplasty and stenting of intracranial arteries in patients with cerebrovascular symptoms adds nothing to medical management. James W. Mold, MD, MPH

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Importance: Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes.

Objective: To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis.

Design, setting, and participants: Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019).

Interventions: Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control.

Main outcomes and measures: The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years.

Results: Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08).

Conclusions and relevance: Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis.

Trial registration: ClinicalTrials.gov Identifier: NCT01763320.

Author/s:

Gao, P., Wang, T., Wang, D., Liebeskind, D. S.", H., Li, T., Zhao, Z., Cai, Y., Wu, W., He, W., Yu, J., Zheng, B., Wang, H., Wu, Y., Dmytriw, A. A., Krings, T., Derdeyn, C. P., Jiao, L., CASSISS Trial Investigators

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

Saige Blanchard — Fri, 21 May 2021 05:00:00 +0000

Date Added:

May 21, 2021

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

May 20, 2021

Issue:

Volume:

384

Pages:

1921-1930

URL:

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa1901281

Keywords

PMID (1):

34010531

MeSH

blood-pressure

cardiovascular diseases

acute coronary syndrome

myocardial infarction

heart failure

hypotension

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

In patients at high risk for cardiovascular events, intensive BP control (target <120 systolic) reduced the rate of adverse CV events (CAD events, CVA, CHF, or death) by 0.63% per year. Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. James W. Mold, MD, MPH

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Background: In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected.

Methods: We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016.

Results: At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups.

Conclusions: Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).

Author/s:

Lewis, C. E., Fine, L. J., Beddhu, S., Cheung, A. K., Cushman, W. C., Cutler, J. A., Evans, G. W., Johnson, K. C., Kitzman, D. W., Oparil, S., Rahman, M., Reboussin, D. M., Rocco, M. V., Sink, K, M., Snyder, J. K., Whelton, P. K., Williamson, J. D., Wright Jr., J. T., Ambrosius, W. T.

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

Devin Evans — Fri, 19 Mar 2021 05:00:00 +0000

Date Added:

March 19, 2021

Journal/Publication:

Journal of the American Medical Association

Publication Date:

March 16, 2021

Issue:

Volume:

325

Pages:

1088-1098

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2020.26867

Keywords

transient ischemic attack

Acute Ischemic Stroke

PMID (1):

33724327

MeSH

Tissue Plasminogen Activator

Platelet Aggregation Inhibitors

ischemic attack, transient

Screening for Asymptomatic Carotid Artery Stenosis US Preventive Services Task Force Recommendation Statement

A non-systematic review of the diagnosis and management of patients with transient ischemic attack and acute stroke. James W. Mold, MD, MPH

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Importance: Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually.

Observations: Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]).

Conclusions and relevance: Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.

Author/s:

Mendelson, Scott J., Prabhakaran, Shyam

Screening for Asymptomatic Carotid Artery Stenosis US Preventive Services Task Force Recommendation Statement

Devin Evans — Thu, 04 Feb 2021 06:00:00 +0000

Date Added:

February 4, 2021

Journal/Publication:

Journal of the American medical Association

Publication Date:

February 2, 2021

Issue:

Volume:

325

Pages:

476-481

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2020.26988

Keywords

US Preventive Services Task Force

Asymptomatic Carotid Artery Stenosis

PMID (1):

33528542

MeSH

Carotid Stenosis

ischemic attack, transient

Constriction, Pathologic

Brain Ischemia

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

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

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

John Bayhi — Fri, 28 Feb 2020 14:21:39 +0000

Date Added:

February 28, 2020

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

February 5, 2020

Issue:

Volume:

Pages:

e200107

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.0107

Keywords

PMID (1):

32101311

MeSH

acute coronary syndrome

coronary artery disease

Platelet Aggregation Inhibitors

Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation

hemorrhage

Registries

The results of this cohort study suggest that for patients with atrial fibrillation, adding an antiplatelet agent to an oral anticoagulant results in more strokes and bleeding and does not protect them from MI. James W. Mold, MD, MPH

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IMPORTANCE:

Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy.

OBJECTIVE:

To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019.

EXPOSURE:

Participants received either OAC plus AP or OAC alone.

MAIN OUTCOMES AND MEASURES:

Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications.

RESULTS:

A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months).

CONCLUSIONS AND RELEVANCE:

This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation.

Author/s:

Fox, KAA, Velentgas, P, Camm, AJ, Bassand, JP, Fitzmaurice, DA, Gersh, BJ, Goldhaber, SZ, Goto, S, Haas, S, Misselwitz, F, Pieper, KS, Turpie, AGG, Verhegut, FWA, Dabrowski, E, Luo, K, Gibbs, L, Kakkar, AK, GARFIELD-AF Investigators

Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation

John Bayhi — Thu, 12 Sep 2019 13:06:34 +0000

Date Added:

September 12, 2019

Journal/Publication:

The American Journal of Cardiology

Publisher:

Elsevier Inc.

Publication Date:

September 15, 2019

Issue:

Volume:

124

Pages:

879-885

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.amjcard.2019.05.072

Keywords

coronary artery disease

CAD

myocardial infarction

PMID (1):

31311662

MeSH

Percutaneous Coronary Intervention

coronary artery disease

myocardial infarction

anticoagulants

Left Atrial Appendages Occlusion: Current Status and Prospective

This systematic review found that it is unwise to add low-dose aspirin to warfarin in patients with CAD and non-valvular atrial fibrillation (no benefit; more bleeding). James W. Mold, MD, MPH

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Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.

Author/s:

Lee, SR, Rhee, TM, Kang, DY, Choi, EK, Oh, S, Lip, GYH

Left Atrial Appendages Occlusion: Current Status and Prospective

Brian Desmarais — Mon, 05 Aug 2019 18:23:22 +0000

Date Added:

August 5, 2019

Journal/Publication:

Korean Circulation Journal

Publication Date:

August 28, 2018

Issue:

Volume:

Pages:

692-704

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.4070/kcj.2018.0231

Keywords

Watchman device

left atrial appendage

MeSH

For those wanting to know more about the Watchman device and other approaches to left atrial appendage occlusion for prevention of stroke due to atrial fibrillation, this was the best recent review article I could find. James W. Mold, MD, MPH

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Stroke continues to be a major cause of morbidity and mortality in atrial fibrillation (AF) patients. Oral anticoagulation (OAC) provides protection against stroke and peripheral embolization in AF but significant proportion of patients could not be started on anticoagulation because of bleeding complications. Left atrial appendage harbors clot in about 90% of nonvalvular AF. The advent of left atrial appendage occlusion (LAAO) techniques has provided these patients with alternative to OAC for stroke prophylaxis. Multiple LAAO devices are currently available with Watchman and Amulet being the most commonly used in clinical practice. Randomized studies are available for Watchman device only. Data on Amplatzer Cardiac Plug, Amulet and Lariat devices are limited by the paucity of randomized data. Long-term data on different LAAO techniques are showing promising results. Device related thrombosis continues to be a serious complication associated with LAAO. Future studies should look into comparative effectiveness between different LAAO techniques, optimal patient selection, risk of complications, and anticoagulant treatment after LAAO. This article aims to provide current available evidence on efficacy and safety of different LAAO devices and future prospective.

Author/s:

Sharma, S.P., Park, P., Lakkireddy, D.

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

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

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.

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

Brian Desmarais — Wed, 12 Jun 2019 01:48:41 +0000

Date Added:

June 11, 2019

Journal/Publication:

Annals of Internal Medicine

Publication Date:

June 11, 2019

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M19-0223

Keywords

cardiovascular

MeSH

White Coat Hypertension

Blood Pressure Determination

cardiovascular diseases

Research Personnel

hypertension

National Institutes of Health (U.S.)