Abstract The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; ...however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Type 2 diabetes mellitus (T2DM) has shown to be associated with carotid plaque vulnerability. However, the impact of T2DM on intracranial artery atherosclerosis is not well‐understood.
...Purpose
To evaluate the association of diabetes and glycemic control with intracranial atherosclerotic plaque characteristics identified by three‐dimensional contrast enhanced MR vessel wall imaging in patients after acute ischemic stroke.
Study Type
Prospective.
Population
Two hundred and eighty‐eight symptomatic patients with acute ischemic stroke due to intracranial atherosclerotic plaque.
Field Strength/Sequence
T1WI volume isotropic turbo spin‐echo acquisition sequence at 3.0 T.
Assessment
Clinical profiles, blood biomarkers, the number of intracranial plaques, plaque enhanced score, and the features (location, luminal stenotic rate, intraplaque hemorrhage, length, burden, enhancement grade, and ratio) of culprit plaque (defined as the most stenotic lesion ipsilateral to the ischemic event) and nonculprit plaque were analyzed by three radiologists.
Statistical Tests
Analysis of variance (ANOVA), Shapiro–Wilk normality test, Levene's test, ANOVA with Bonferroni post‐hoc test, Kruskal Wallis H test with subsequent pairwise comparisons, chi‐square with Bonferroni post‐hoc test, generalized linear regression, Pearson correlation test, Kendall's W and intra‐class correlation coefficient.
Results
Two hundred and twenty‐five participants (age 60 ± 10 years, 58.7% male) with 958 intracranial plaques were included. More intracranial plaques were found in the T2DM group than the non‐T2DM group (4.80 ± 2.22 vs. 3.60 ± 1.78, P < 0.05). Patients with poorly‐controlled T2DM exhibited higher culprit plaque enhancement ratio than patients with well‐controlled T2DM and non‐T2DM (2.32 ± 0.61 vs. 1.60 ± 0.62 and 1.39 ± 0.39; respectively, P < 0.05). After adjusting for other clinical variables, T2DM was independently associated with increased intracranial plaque number (β = 0.269, P < 0.05), and HbA1c level was independently associated with culprit plaque enhancement ratio (β = 0.641, P < 0.05) in multivariate analysis.
Data Conclusion
T2DM is associated with an increased intracranial plaque number. Higher HbA1c is associated with stronger plaque enhancement. 3D contrast enhanced MR vessel wall imaging may help better understand the association of T2DM and glycemic control with intracranial plaque.
Level of Evidence
1
Technical Efficacy Stage
3
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of ...critical care by different specialties. Methods We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics. Results Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine ( P < .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians ( P < .05). Chart documentation of indicators of palliative care differed by attending specialty. Conclusions Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These findings may provide insights into potential ways to improve the quality of dying for all patients. Trial registry ClinicalTrials.gov ; No.: NCT00685893; URL: www.clinicaltrials.gov
Previous studies suggest that genetic variation plays a substantial role in occurrence and evolution of intracerebral hemorrhage (ICH). Genetic contribution to disease can be determined by ...calculating heritability using family-based data, but such an approach is impractical for ICH because of lack of large pedigree-based studies. However, a novel analytic tool based on genome-wide data allows heritability estimation from unrelated subjects. We sought to apply this method to provide heritability estimates for ICH risk, severity, and outcome.
We analyzed genome-wide genotype data for 791 ICH cases and 876 controls, and determined heritability as the proportion of variation in phenotype attributable to captured genetic variants. Contribution to heritability was separately estimated for the APOE (encoding apolipoprotein E) gene, an established genetic risk factor, and for the rest of the genome. Analyzed phenotypes included ICH risk, admission hematoma volume, and 90-day mortality.
ICH risk heritability was estimated at 29% (SE, 11%) for non-APOE loci and at 15% (SE, 10%) for APOE. Heritability for 90-day ICH mortality was 41% for non-APOE loci and 10% (SE, 9%) for APOE. Genetic influence on hematoma volume was also substantial: admission volume heritability was estimated at 60% (SE, 70%) for non-APOEloci and at 12% (SE, 4%) for APOE.
Genetic variation plays a substantial role in ICH risk, outcome, and hematoma volume. Previously reported risk variants account for only a portion of inherited genetic influence on ICH pathophysiology, pointing to additional loci yet to be identified.
BACKGROUND AND PURPOSE—Increased sympathetic tone causes hypertension after intracerebral hemorrhage, and blood pressure reduction has been studied as a way to decrease hemorrhage growth and improve ...outcomes. It is unknown if the antihypertensive used to achieve blood pressure goals influences either. Because sympatholytic drugs reduce death and infection in animal models, we hypothesized that labetalol would improve outcomes compared with nicardipine.
METHODS—Prospective data from a single center were retrospectively reviewed. Patients receiving labetalol, nicardipine, or both during their first 3 days of hospitalization were included. Outcomes included in-hospital death; discharge modified Rankin Score >2; and in-hospital urinary tract infection, pneumonia, or bacteremia. Patients were compared with propensity scoring and analyzed with linear models adjusted for significant confounders.
RESULTS—Of 1066 admissions, 525 were treated with labetalol or nicardipine and are included; 229 (43.6%) received labetalol, 107 (20.4%) received nicardipine, and 189 (36.0%) received both. Mortality and infection rates were 40.2% and 15.8%, respectively, 77.2% had a modified Rankin Score >2. After adjustment, compared with nicardipine alone, labetalol alone was associated with infection (odds ratio, 3.12; confidence interval, 1.27–7.64; P=0.013) but not when combined with nicardipine (odds ratio, 2.44; confidence interval, 0.98–6.07; P=0.055). Labetalol, with or without nicardipine, was not associated with death or discharge modified Rankin Score >2.
CONCLUSIONS—Compared with nicardipine, labetalol was associated with increased in-hospital infections, but not mortality or modified Rankin Score >2. These findings do not support our hypothesis that labetalol use improves outcomes relative to nicardipine in intracerebral hemorrhage.
The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these ...guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.
OBJECTIVESA systematic review of somatosensory evoked potentials performed early after onset of coma, to predict the likelihood of nonawakening. The pooled results were evaluated for rates of ...awakening, confidence intervals, and the possibility of rare exceptions.
DATA SOURCESForty-one articles reporting somatosensory evoked potentials in comatose patients and subsequent outcomes, from 1983 to 2000.
STUDY SELECTIONStudies were included if they reported coma etiology, age group, presence or absence of somatosensory evoked potentials, and coma outcomes.
DATA EXTRACTIONWe separated patients into four groupsadults with hypoxic-ischemic encephalopathy, adults with intracranial hemorrhage, adults and adolescents with traumatic brain injury, and children and adolescents with any etiologies. Somatosensory evoked potentials were categorized as normal, abnormal, or bilaterally absent. Outcomes were categorized as persistent vegetative state or death vs. awakening.
DATA SYNTHESISFor each somatosensory evoked potential result, rates of awakening (95% confidence interval) were calculatedadult hypoxic-ischemic encephalopathyabsent 0% (0%–1%), abnormal 22% (17%–26%), normal 52% (48%–56%); adult intracranial hemorrhageabsent 1% (0%–4%), present 38% (27%–48%); adult-teen traumatic brain injuryabsent 5% (2%–7%), abnormal 70% (64%–75%), normal 89% (85%–92%); child-teenabsent 7% (4%–10%), abnormal 69% (61%–77%), normal 86% (80%–92%).
CONCLUSIONSSomatosensory evoked potential results predict the likelihood of nonawakening from coma with a high level of certainty. Adults in coma from hypoxic-ischemic encephalopathy with absent somatosensory evoked potential responses have <1% chance of awakening.
In 2017, the Centers for Disease Control and Prevention (CDC) issued an alert that, after decades of consistent decline, the stroke death rate levelled off in 2013, particularly in younger ...individuals and without clear origin. The objective of this analysis was to understand whether social determinants of health have influenced trends in stroke mortality.
We performed a longitudinal analysis of county-level ischemic and hemorrhagic stroke death rate per 100,000 adults from 1999 to 2018 using a Bayesian spatiotemporally smoothed CDC dataset stratified by age (35-64 years younger and 65 years or older older) and then by county-level social determinants of health. We reported stroke death rate by county and the percentage change in stroke death rate during 2014-2018 compared with that during 2009-2013.
We included data from 3,082 counties for younger individuals and 3,019 counties for older individuals. The stroke death rate began to increase for younger individuals in 2013 (
< 0.001), and the slope of the decrease in stroke death rate tapered for older individuals (
< 0.001). During the 20-year period of our study, counties with a high social deprivation index and ≥10% Black residents consistently had the highest rates of stroke death in both age groups. Comparing stroke death rate during 2014-2018 with that during 2009-2013, larger increases in younger individuals' stroke death rate were seen in counties with ≥90% (vs <90%) non-Hispanic White individuals (3.2% mean death rate change vs 1.7%,
< 0.001), rural (vs urban) populations (2.6% vs 2.0%,
= 0.019), low (vs high) proportion of medical insurance coverage (2.9% vs 1.9%,
= 0.002), and high (vs low) substance abuse and suicide mortality (2.8 vs 1.9%,
= 0.008; 3.3% vs 1.5%,
< 0.001). In contrast to the younger individuals, in older individuals, the associations with increased death rates were with more traditional social determinants of health such as the social deprivation index, urban location, unemployment rate, and proportion of Black race and Hispanic ethnicity residents.
Improvements in the stroke death rate in the United States are slowing and even reversing in younger individuals and many US counties. County-level increases in stroke death rate were associated with distinct social determinants of health for younger vs older individuals. These findings may inform targeted public health strategies.
Abstract only Objective: Improve the institution of NIH Stroke scale (NIHSS) and outcomes of Stroke codes in low English proficiency population (LEP) at a comprehensive stroke center. Background: LEP ...individuals are those with limited ability to read, write, speak, or understand English. The 2000 national census showed 47 million U.S. citizens/residents aged 5 years and older spoke a language other than English at home. This is projected to grow by 67 million by 2050. For patients from culturally and linguistically diverse backgrounds, language barriers contribute to poorer quality of care. Stroke is a leading cause of serious long-term disability and death and our aim is to ensure that time-sensitive interventions during a Stroke code are available to our LEP patients in the most efficient and fastest manner. Design/Methods: 1) Pre-intervention survey of providers 2) Creating a set of English words that are more internationally used to assess dysarthria 3) Interpreter Education (for select languages) regarding stroke, acuity of Stroke codes, NIHSS content, tPA and thrombectomy 4) Easy access for providers to the trained interpreters and use of the new Dysarthria words 5) Post-intervention survey of providers running Stroke code 6) Compare post-intervention door-to-needle and door-to-thrombectomy times in languages intervened to other languages in the same period of time. Results: Pre-intervention survey shows that 84.6% of the providers (n=26) deemed running LEP stroke codes in a time-efficient manner as difficult or very difficult. 50% found getting a telephonic interpreter to start the communication to be slow/very slow. 88.5% found the telephonic providers to be either somewhat helpful or not so helpful during the code. 92% of the providers found the words to test dysarthria on the NIHSS to be not helpful in LEP stroke patients. ConclusionS: It is apparent that LEP Stroke codes can be improved based on the above provider opinions. Therefore, we have set into motion a multi-pronged strategy by rethinking the contents of NIHSS, interpreter education and finally instituting an intervention based on the same. The study has started the final phase of having providers access the trained interpreters. The data of the latter will be collected in about 2 years’ time.
To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in ...body structure/function (motor impairment) most related to mRS gains.
Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.
At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 2-3 30 days posttherapy (
< 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (
= 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score,
= 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.
Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.
Clinicaltrials.gov identifier: NCT02360488.
This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.
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