stroke

Patent Foramen Ovale and Stroke A Review

In patients with high-risk CAD already on an anticoagulant, the addition of aspirin increases the risk of adverse events. James W. Mold, MD, MPH

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Background: The appropriate antithrombotic regimen for patients with chronic coronary syndrome who are at high atherothrombotic risk and receiving long-term oral anticoagulation remains unknown.

Methods: We conducted a multicenter, double-blind, randomized, placebo-controlled trial in France involving patients with chronic coronary syndrome who had undergone a previous stent implantation (>6 months before enrollment) and were at high atherothrombotic risk and currently receiving long-term oral anticoagulation. The patients were randomly assigned in a 1:1 ratio to receive aspirin (100 mg once daily) or placebo; all the patients continued to receive their current oral anticoagulation therapy. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, stroke, systemic embolism, coronary revascularization, or acute limb ischemia. The key safety outcome was major bleeding.

Results: A total of 872 patients underwent randomization; 433 were assigned to the aspirin group, and 439 to the placebo group. The trial was stopped early at the advice of the independent data and safety monitoring board after a median follow-up of 2.2 years because of an excess of deaths from any cause in the aspirin group. A primary efficacy outcome event occurred in 73 patients (16.9%) in the aspirin group and in 53 patients (12.1%) in the placebo group (adjusted hazard ratio, 1.53; 95% confidence interval [CI], 1.07 to 2.18; P = 0.02). Death from any cause occurred in 58 patients (13.4%) in the aspirin group and in 37 (8.4%) in the placebo group (adjusted hazard ratio, 1.72; 95% CI, 1.14 to 2.58; P = 0.01). Major bleeding occurred in 44 patients (10.2%) in the aspirin group and in 15 patients (3.4%) in the placebo group (adjusted hazard ratio, 3.35; 95% CI, 1.87 to 6.00; P<0.001). A total of 467 and 395 serious adverse events were reported in the aspirin group and placebo group, respectively.

Conclusions: Among patients with chronic coronary syndrome at high atherothrombotic risk who were receiving an oral anticoagulant, the addition of aspirin led to a higher risk of cardiovascular death, myocardial infarction, stroke, systemic embolism, coronary revascularization, or acute limb ischemia than placebo, as well as higher risks of death from any cause and major bleeding. (Funded by the French Ministry of Health and Bayer Healthcare; ClinicalTrials.gov number, NCT04217447.).

Author/s:

Gilles Lemesle, M.D., Ph.D., Romain Didier, M.D., Ph.D., Philippe Gabriel Steg, M.D., Tabassome Simon, M.D., Ph.D., Gilles Montalescot, M.D., Ph.D., Nicolas Danchin, M.D., Christophe Bauters, M.D., Ph.D.

Patent Foramen Ovale and Stroke A Review

Hope Smashey — Tue, 29 Jul 2025 17:14:31 +0000

Date Added:

July 29, 2025

Journal/Publication:

JAMA

Publication Date:

July 28, 2025

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2025.10946

Keywords

Congenital Defects

pediatrics

female

PMID (1):

40720119

MeSH

Apparently patent foramen ovale is a lot more common than many of us thought they were and an important cause of embolic strokes. James W. Mold, MD, MPH

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Importance: A patent foramen ovale (PFO), an opening between the right and left atria during normal fetal development that fails to close after birth, is present in approximately 25% of all adults. Paradoxical embolism, a venous thromboembolism that travels to the systemic circulation typically through a PFO, accounts for about 5% of all strokes and 10% of strokes in younger patients.

Observations: Approximately 50% of patients 60 years or younger with an embolic stroke of undetermined source (cryptogenic stroke) have a PFO, compared with 25% of the general population. The Risk of Paradoxical Embolism (RoPE) score incorporates clinical characteristics (age, history of stroke or transient ischemic attack, diabetes, hypertension, smoking, cortical infarct on imaging) to predict the likelihood that embolic stroke of undetermined source was caused by a PFO. Among patients in the lowest RoPE score category (score <3), PFO prevalence was similar to that in the general population (23%), while PFO prevalence was 77% in patients with a RoPE score of 9 or 10. The PFO-Associated Stroke Causal Likelihood (PASCAL) classification system combines the RoPE score and anatomical criteria from echocardiography (large shunt, atrial septal aneurysm) to classify PFO as the “probable,” “possible,” or “unlikely” cause of otherwise cryptogenic stroke. PFO closure reduces recurrent ischemic stroke in patients 60 years or younger with cryptogenic stroke. In a pooled analysis of 6 trials (3740 patients), the annualized incidence of stroke over a median follow-up of 57 months was 0.47% (95% CI, 0.35%-0.65%) with PFO closure vs 1.09% (95% CI, 0.88%-1.36%) with medical therapy (adjusted hazard ratio, 0.41 [95% CI, 0.28-0.60]). However, the benefits and harms of closure were highly heterogeneous across the trial populations. In patients categorized as PASCAL “probable” (ie, younger patients without vascular risk factors and high-risk PFO anatomical features), there was a 90% decreased relative rate of recurrent ischemic stroke after PFO closure at 2 years (hazard ratio, 0.10 [95% CI, 0.03-0.35]; absolute risk reduction, 2.1% [95% CI, 0.9%-3.4%]). PASCAL “unlikely” patients (eg, older patients with vascular risk factors and no high-risk PFO anatomical features) did not have a lower recurrent stroke rate with PFO closure but had higher risk of procedure- and device-related adverse events, such as atrial fibrillation.

Conclusions and Relevance: Patent foramen ovale is present in approximately 25% of all adults and is a common cause of stroke in young and middle-aged patients. The PASCAL classification system can help guide patient selection for PFO closure. Percutaneous PFO closure substantially reduces the risk of stroke recurrence in well-selected patients younger than 60 years after cryptogenic stroke.

Author/s:

David M. Kent, Andy Y. Wang

Early Invasive or Conservative Strategies for Older Patients With Acute Coronary Syndromes: A Meta-Analysis

Hope Smashey — Tue, 01 Jul 2025 19:20:08 +0000

Date Added:

July 1, 2025

Journal/Publication:

JAMA Intern Medicine

Publication Date:

June 23, 2025

URL:

Early Invasive or Conservative Strategies for Older Patients With Acute Coronary Syndromes: A Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2025.2058

Keywords

PMID (1):

40549394

MeSH

acute coronary syndrome

conservative treatment

heart failure

What Is Atrial Fibrillation?

aged

In patients over the age of 70 who experience a heart attack, it appears that non-intervention is as good as early intervention considering the increased risk of bleeding. James W. Mold, MD, MPH

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Importance: The optimal management strategy for older patients who present with acute coronary syndrome (ACS) remains unclear due to a paucity of randomized evidence. New large and longer-term randomized data are available.

Objective: To test the association of an early invasive strategy vs a conservative strategy with clinical outcomes for patients 70 years or older who present with ACS.

Data sources: A literature search strategy was designed in collaboration with a medical librarian. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched ,with no language restrictions from inception through October 2024. Bibliographies of previous reviews and conference abstracts from major cardiovascular scientific meetings were handsearched.

Study selection: Studies were deemed eligible following review by 2 independent, masked investigators if they randomly allocated patients 70 years or older who presented with ACS to early invasive or conservative management and reported clinical end points. Observational analyses were excluded. No trials were excluded based on sample size or follow-up duration.

Data extraction and synthesis: Data were extracted independently and in triplicate. Clinical end points were pooled in meta-analyses that applied fixed-effects and random-effects modeling to calculate summary estimates for relative risks (RRs) and hazard ratios, along with their corresponding 95% CIs.

Main outcomes and measures: The prespecified primary end point was all-cause death. Secondary end points included recurrent myocardial infarction (MI), repeated coronary revascularization, major bleeding, cardiovascular death, death or MI, stroke, heart failure hospitalization, major adverse cardiac events, major adverse cardiovascular or cerebrovascular events, and length of hospital stay.

Results: The sample size-weighted mean age of participants across included trials was 82.6 years, and 46% were female. In the pooled analysis, there was no significant difference in all-cause death between the invasive and conservative strategies (RR, 1.05; 95% CI, 0.98-1.11; P = .15; I2 = 0%). An early invasive strategy was associated with a reduced risk of recurrent MI of 22% (RR, 0.78; 95% CI, 0.67-0.91; P = .001; I2 = 0%) and repeated coronary revascularization during follow-up of 57% (RR, 0.43; 95% CI, 0.30-0.60; P < .001; I2 = 33.3%). However, an invasive strategy was associated with an increased risk of major bleeding (RR, 1.60; 95% CI, 1.01-2.53; P = .05; I2 = 16.7). No differences were observed in secondary end points. Results in the non-ST-elevation ACS population were consistent with the overall findings.

Conclusions and relevance: The results of this systematic review and meta-analysis suggest that, in older patients with ACS, an early invasive strategy was not associated with reduced all-cause death compared with conservative management. An early invasive strategy was associated with reduced recurrent MI and repeated coronary revascularization during follow-up but increased risk of major bleeding. Competing risks associated with an early invasive strategy should be weighed in shared therapeutic decision-making for older patients with ACS.

Author/s:

Rohin K Reddy, David Koeckerling, Christian Eichhorn, Yasser Jamil, Maddalena Ardissino, Volker Braun, Haitham Abu Sharar, Norbert Frey, James P Howard, Yousif Ahmad

What Is Atrial Fibrillation?

Erin Blanchette — Wed, 30 Apr 2025 21:32:57 +0000

Date Added:

April 30, 2025

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

April 24, 2025

URL:

Type:

Patient Education Materials

Format:

Article

DOI (1):

10.1001/jama.2025.2888

Keywords

atrial fibrillation

Cardiology

Patient Information

jama Patient Information

Rhythm Disorders

PMID (1):

40272794

MeSH

hypertension

Invasive Versus Conservative Treatment Strategy in Older Patients With Non-ST Segment Elevation Acute Coronary Syndromes: A Meta-Analysis of Randomized Controlled Trials

sleep apnea syndromes

Information for patients about atrial fibrillation. James W. Mold, MD, MPH

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Atrial fibrillation is an abnormal heart rhythm that can cause stroke, heart failure, heart attack, chronic kidney disease, dementia, and death.

Atrial fibrillation is classified as paroxysmal (intermittent episodes lasting 7 days or less), persistent (lasting more than 7 days), long-standing persistent (lasting more than 1 year), or permanent.1

In the US, atrial fibrillation affects about 10.55 million people and is more common among men than women. Other risk factors include older age, smoking, high blood pressure, diabetes, heart disease, high alcohol consumption, sleep apnea, an overactive thyroid gland, and possibly genetic factors.

Author/s:

Rebecca Voelker

Invasive Versus Conservative Treatment Strategy in Older Patients With Non-ST Segment Elevation Acute Coronary Syndromes: A Meta-Analysis of Randomized Controlled Trials

Alex Haga — Mon, 31 Mar 2025 13:51:29 +0000

Date Added:

March 31, 2025

Journal/Publication:

J Am Geriatr Soc .

Publication Date:

March 26, 2025

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1111/jgs.19447

Keywords

NSTEMI

Conservative treatment

invasive treatment

revascularization

unstable angina pectoris

PMID (1):

40135822

MeSH

acute coronary syndrome

conservative treatment

Management of Atrial Fibrillation

Revascularization may reduce subsequent MI and invasive procedures but not mortality compared to conservative care in older patients following non-ST elevation MI. James W. Mold, MD, MPH

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Background
Non-ST segment elevation acute coronary syndromes (NSTE-ACS) are a common cause of hospital admission in older patients. Our study aims to synthesize the available evidence from randomized controlled trials (RCTs) to compare clinical outcomes with invasive versus conservative medical management in this population.

Methods
A literature search of online databases including PubMed/MEDLINE, Embase, and the Cochrane Library was conducted from inception to September 1, 2024. The search aimed to identify RCTs that reported clinical outcomes with invasive versus conservative strategies in older patients (≥ 70 years) with NSTE-ACS. The risk ratios (RRs) were used as summary estimates.

Results
Seven RCTs with 2998 patients were included; 1490 patients in the invasive group and 1508 patients in the conservatively managed group. The pooled analysis demonstrated no statistically significant difference between the two strategies for the risk of all-cause death (RR: 1.03, 95% CI: 0.92–1.15), cardiovascular death (RR: 1.04, 95% CI: 0.82–1.33), stroke (RR: 0.78, 95% CI: 0.53–1.15), and major bleeding (RR: 1.23, 95% CI: 0.90–1.69). However, the invasive strategy was associated with a significantly reduced risk of myocardial infarction (RR: 0.74, 95% CI: 0.57–0.96) and unplanned revascularization (RR: 0.29, 95% CI: 0.21–0.40) compared to the conservative strategy.

Conclusion
In older patients with NSTE-ACS, an invasive strategy reduces the risk of repeat myocardial infarction and unplanned revascularization without a significant increase in stroke or major bleeding. There was no associated reduction in all-cause or cardiovascular mortality with the invasive strategy compared to conservative management.

Author/s:

Mushood Ahmed, Areeba Ahsan, Aimen Shafiq, Tallal Mushtaq Hashmi

Management of Atrial Fibrillation

Erin Blanchette — Mon, 18 Nov 2024 14:34:46 +0000

Date Added:

November 18, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

November 14, 2024

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.19565

Keywords

atrial fibrillation

Atrial Fibrillation* / diagnosis

PMID (1):

39541112

MeSH

atrial fibrillation

Platelet Aggregation Inhibitors

Mitral Valve Stenosis

Atrial Appendage

heart failure

Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial

2023 guidelines from the ACC/AHA/ACCP/HRS on treatment of patients with atrial fibrillation. James W. Mold, MD, MPH

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Atrial fibrillation has a lifetime prevalence of 15% to 40% and predisposes patients to stroke and cardiac dysfunction. This JAMA Clinical Guidelines Synopsis focuses on recommendations for long-term management of AF, including new paradigms for rhythm control and stroke risk reduction.

Author/s:

Francis J Alenghat, Jason T Alexander, Gaurav A Upadhyay

Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial

Aubrey Delammermore — Sat, 22 Oct 2022 05:00:00 +0000

Date Added:

October 22, 2022

Journal/Publication:

The Lancet

Publisher:

Elsevier

Publication Date:

October 11, 2022

Issue:

10361

Volume:

400

Pages:

1417-1425

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/S0140-6736(22)01786-X

Keywords

Intention to Treat Analysis

Antihypertensive Agents

Cardiovascular Diseases

Surveys and Questionnaires

United Kingdom

PMID (1):

36240838

MeSH

antihypertensive agents

Time and Motion Studies

hypertension

Patient Acceptance of Health Care

In this large RCT, evening dosing of antihypertensive drugs was no better than morning dosing in regard to cardiovascular outcomes. James W. Mold, MD, MPH

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Background: Studies have suggested that evening dosing with antihypertensive therapy might have better outcomes than morning dosing. The Treatment in Morning versus Evening (TIME) study aimed to investigate whether evening dosing of usual antihypertensive medication improves major cardiovascular outcomes compared with morning dosing in patients with hypertension.

Methods: The TIME study is a prospective, pragmatic, decentralised, parallel-group study in the UK, that recruited adults (aged ≥18 years) with hypertension and taking at least one antihypertensive medication. Eligible participants were randomly assigned (1:1), without restriction, stratification, or minimisation, to take all of their usual antihypertensive medications in either the morning (0600-1000 h) or in the evening (2000-0000 h). Participants were followed up for the composite primary endpoint of vascular death or hospitalisation for non-fatal myocardial infarction or non-fatal stroke. Endpoints were identified by participant report or record linkage to National Health Service datasets and were adjudicated by a committee masked to treatment allocation. The primary endpoint was assessed as the time to first occurrence of an event in the intention-to-treat population (ie, all participants randomly assigned to a treatment group). Safety was assessed in all participants who submitted at least one follow-up questionnaire. The study is registered with EudraCT (2011-001968-21) and ISRCTN (18157641), and is now complete.

Findings: Between Dec 17, 2011, and June 5, 2018, 24 610 individuals were screened and 21 104 were randomly assigned to evening (n=10 503) or morning (n=10 601) dosing groups. Mean age at study entry was 65·1 years (SD 9·3); 12 136 (57·5%) participants were men; 8968 (42·5%) were women; 19 101 (90·5%) were White; 98 (0·5%) were Black, African, Caribbean, or Black British (ethnicity was not reported by 1637 [7·8%] participants); and 2725 (13·0%) had a previous cardiovascular disease. By the end of study follow-up (March 31, 2021), median follow-up was 5·2 years (IQR 4·9-5·7), and 529 (5·0%) of 10 503 participants assigned to evening treatment and 318 (3·0%) of 10 601 assigned to morning treatment had withdrawn from all follow-up. A primary endpoint event occurred in 362 (3·4%) participants assigned to evening treatment (0·69 events [95% CI 0·62-0·76] per 100 patient-years) and 390 (3·7%) assigned to morning treatment (0·72 events [95% CI 0·65-0·79] per 100 patient-years; unadjusted hazard ratio 0·95 [95% CI 0·83-1·10]; p=0·53). No safety concerns were identified.

Interpretation: Evening dosing of usual antihypertensive medication was not different from morning dosing in terms of major cardiovascular outcomes. Patients can be advised that they can take their regular antihypertensive medications at a convenient time that minimises any undesirable effects.

Funding: British Heart Foundation.

Author/s:

Mackenzie, I. S., Rogers, A., Poulter, N. R., Williams, B., Brown, M. J., Webb, D. J., Ford, I., Rorie, D. A., Guthrie, G., Grieve, J. W. K., Pigazzani, F., Rothwell, P. M., Young, R., McConnachie, A., Struthers, A. D., Lang, C. C., MacDonald, T. M.

Use of Recommended Health Care Measures to Prevent Selected Complications of Sickle Cell Anemia in Children and Adolescents — Selected U.S. States, 2019

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

Morbidity and Mortality Weekly Report

Publisher:

US Department of Health and Human Services

Publication Date:

September 20, 2022

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.15585/mmwr.mm7139e1

Keywords

MeSH

Recommendations from the CDC regarding prevention of complications children with sickle cell anemia. James W. Mold, MD, MPH

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Introduction: Sickle cell disease (SCD), a group of inherited blood cell disorders that primarily affects Black or African American persons, is associated with severe complications and a >20-year reduction in life expectancy. In 2014, an expert panel convened by the National Heart, Lung, and Blood Institute issued recommendations to prevent or reduce complications in children and adolescents with the most severe SCD subtypes, known as sickle cell anemia (SCA); recommendations included 1) annual screening of children and adolescents aged 2–16 years with transcranial Doppler (TCD) ultrasound to identify those at risk for stroke and 2) offering hydroxyurea therapy to children and adolescents aged ≥9 months to reduce the risk for several life-threatening complications.

Methods: Data from the IBM MarketScan Multi-State Medicaid Database were analyzed. TCD screening and hydroxyurea use were examined for 3,352 children and adolescents with SCA aged 2–16 years and continuously enrolled in Medicaid during 2019. Percentage change during 2014–2019 and variation by health subgroups were assessed. Analyses were stratified by age.

Results: During 2014–2019, TCD screening increased 27% among children and adolescents aged 10–16 years; hydroxyurea use increased 27% among children aged 2–9 years and 23% among children and adolescents aged 10–16 years. However, in 2019, only 47% and 38% of children and adolescents aged 2–9 and 10–16 years, respectively, had received TCD screening and 38% and 53% of children and adolescents aged 2–9 years and 10–16 years, respectively, used hydroxyurea. For both prevention strategies, usage was highest among children and adolescents with high levels of health care utilization and evidence of previous complications indicative of severe disease.

Conclusion and Implications for Public Health Practice: Despite increases since 2014, TCD screening and hydroxyurea use remain low among children and adolescents with SCA. Health care providers should implement quality care strategies within their clinics and partner with patients, families, and community-based organizations to address barriers to delivering and receiving recommended care.

Author/s:

Schieve, L. A., Simmons, G. M., Payne, A. B., Abe, K., Hsu, L. L., Hulihan, M., Pope, S., Rhie, S., Dupervil, B., Hooper, W. C.

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

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

blood pressure

transient ischemic attack

Acute Ischemic Stroke

PMID (1):

33724327

MeSH

Tissue Plasminogen Activator

Platelet Aggregation Inhibitors

ischemic attack, transient

blood pressure

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

Colchicine in Patients with Chronic Coronary Disease

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:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2021372

MeSH

Heart Diseases

Myocardial Ischemia

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

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:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.amjmed.2020.04.028

Keywords

aspirin

primary prevention

Atherosclerotic Cardiovascular Disease

MeSH

cardiovascular diseases

Brain Ischemia

follow-up studies