The cardiovascular risk associated with early renal insufficiency is unknown. Clinicians are often reluctant to use angiotensin-converting enzyme inhibitors in patients with renal insufficiency.
To ...determine whether mild renal insufficiency increases cardiovascular risk and whether ramipril decreases that risk.
Post hoc analysis.
The Heart Outcomes and Prevention Evaluation (HOPE) study, a randomized, double-blind, multinational trial involving 267 study centers.
980 patients with mild renal insufficiency (serum creatinine concentration >/= 124 micromol/L >/=1.4 mg/dL) and 8307 patients with normal renal function (serum creatinine concentration < 124 micromol/L <1.4 mg/dL) Patients with a baseline serum creatinine concentration greater than 200 micromol/L (2.3 mg/dL) were excluded.
The primary outcome measure was incidence of cardiovascular death, myocardial infarction, or stroke.
Cumulative incidence of the primary outcome was higher in patients with renal insufficiency than in those without (22.2% vs. 15.1%; P < 0.001) and increased with serum creatinine concentration. Patients with renal insufficiency had a substantially increased risk for cardiovascular death (11.4% vs. 6.6%) and total mortality (17.8% vs. 10.6%) (P < 0.001 for both comparisons). The effect of renal insufficiency on the primary outcome (adjusted hazard ratio, 1.40 95% CI, 1.16 to 1.69) was independent of known cardiovascular risks and treatment. Ramipril reduced the incidence of the primary outcome in patients with and those without renal insufficiency (hazard ratio, 0.80 vs. 0.79; P > 0.2 for the difference).
In patients who had preexisting vascular disease or diabetes combined with an additional cardiovascular risk factor, mild renal insufficiency significantly increased the risk for subsequent cardiovascular events. Ramipril reduced cardiovascular risk without increasing adverse effects.
Background
Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS).
Aims
We ...undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions.
Methods
Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS.
Results
Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2–8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation.
Conclusions
This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.
Background
About 25% of ischemic strokes are categorized as cryptogenic (i.e. of unknown cause), but few data exist about the extent of diagnostic testing or treatment. We undertook an international ...survey to characterize current diagnostic evaluation and antithrombotic management of patients with cryptogenic ischemic stroke in 2014.
Aims/Hypothesis
To determine the type of diagnostic evaluation undertaken for cryptogenic ischemic stroke and antithrombotic management and to compare across global regions.
Methods
An 18-question online survey was sent to 995 physicians involved in stroke care in 61 countries. Countries were separated into World Bank global regions and income groups. Diagnostic tests were considered routine if performed in >75% of patients at a center.
Results
Three hundred one completed surveys were received from 48 countries (response rate ∼30%). The majority (82%) of hospitals were from high-income countries and mainly from Europe and Central Asia (56%) and North America (19%). For ischemic stroke patients, magnetic resonance imaging is routinely obtained at 36% of hospitals (highest in North America, 58%). Among cryptogenic stroke patients, transesophageal echocardiography is routinely performed in 17% of hospitals. More than 24 hour cardiac rhythm monitoring is done routinely at relatively few (17%) hospitals (highest in North America, 33%). Intracranial arterial imaging is done routinely at 70% of hospitals, with no significant regional differences. Antiplatelet therapies are routinely prescribed for secondary prevention at 94% of hospitals.
Conclusions
Based on self-selected respondents from a large number of international stroke centers, transesophageal echocardiography and prolonged (>24 h) cardiac rhythm monitoring are not routinely performed in cryptogenic stroke patients, even in high-income countries. Antiplatelet therapy is the global standard for secondary prevention of cryptogenic stroke.
The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited ...availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings.
We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion.
A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates.
The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts.
Physical rehabilitation (PR) interventions can improve physical function for adults with frailty; however, participant retention rates in randomized controlled trials (RCTs) are unknown. Objective is ...to summarize participant retention rates in RCTs of PR for adults with frailty. Design is a systematic review and meta-analysis (DOI:10.17605/OSF.IO/G6XR2). Participants are adults ≥ 18 years with frailty. Setting consists of inpatient, outpatient and community-based interventions. Intervention includes any PR intervention.
We searched 7 electronic databases from inception to April 15, 2020 for published RCTs. Our primary outcome was participant retention rate to primary outcome measurement. Secondary outcomes included retention by study group, participant retention to intervention completion, reported reasons for attrition and reported strategies for maximizing retention. We completed screening, data extraction and risk of bias (ROB) assessments independently and in duplicate. We conducted a meta-analysis, calculating retention rates and 95% confidence intervals (CIs) using fixed or random-effects models, as appropriate.
We included 21 RCTs, enrolling 1685 adults with frailty (median age 82.5 years (79.0, 82.2), 59.8% female (57.5, 69.8)). Twenty RCTs reported retention data, of which 90.0% (n = 18) had high ROB. The pooled participant retention rate to primary outcome measurement was 85.0% 95%CI (80.0, 90.0), I
= 83.9%, p < 0.05. There were no differences by group for retention to the primary outcome intervention 87.0% (83.0, 91.0), p < 0.05, comparator 85.0% (79.0, 90.0), p < 0.05 or in retention to intervention completion 83.0% (95.0% CI (78.0-87.0), p < 0.05. Of the 18 studies reporting 24 reasons for attrition, 51.3% were categorized as potentially modifiable by the research team (e.g. low motivation). Only 20.0% (n = 4) of studies reported strategies for maximizing retention.
In this review of 21 RCTs of PR, we identified acceptable rates of retention for adults with frailty. High retention in PR interventions appears to be feasible in this population; however, our results are limited by a high ROB and heterogeneity.
Electrocardiographic markers of left ventricular hypertrophy (LVH) predict poor prognosis. We determined whether the ACE inhibitor ramipril prevents the development and causes regression of ECG-LVH ...and whether these changes are associated with improved prognosis independent of blood pressure reduction.
In the Heart Outcomes Prevention Evaluation (HOPE) study, patients at high risk were randomly assigned to ramipril or placebo and followed for 4.5years. ECGs were recorded at baseline and at study end. We compared prevention/regression and development/persistence of ECG-LVH in the two groups and related these changes to outcomes. At baseline, 676 patients had LVH (321 in the ramipril group and 355 in the placebo group) and 7605 patients did not have LVH (3814 in the ramipril group and 3791 in the placebo group). By study end, 336 patients in the ramipril group (8.1%) compared with 406 in the placebo group (9.8%) had development/persistence of LVH; in contrast, 3799 patients in the ramipril group (91.9%) compared with 3740 in the placebo group (90.2%) had regression/prevention of LVH (P=0.007). The effect of ramipril on LVH was independent of blood pressure changes. Patients who had regression/prevention of LVH had a lower risk of the predefined primary outcome (cardiovascular death, myocardial infarction, or stroke) compared with those who had development/persistence of LVH (12.3% versus 15.8%, P=0.006) and of congestive heart failure (9.3% versus 15.4%, P<0.0001).
The ACE inhibitor ramipril decreases the development and causes regression of ECG-LVH independent of blood pressure reduction, and these changes are associated with reduced risk of death, myocardial infarction, stroke, and congestive heart failure.
Objectives
To examine the association between Mini‐Mental State Examination (MMSE) score and motor vehicle crash (MVC) risk in a large cohort of community‐dwelling participants with cardiovascular ...disease (CVD) or diabetes mellitus.
Design
Prospective observational study.
Setting
Participants enrolled in the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial and Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease clinical trial, which included individuals aged 55 and older with CVD or diabetes mellitus.
Participants
Totally 17,538 frequent drivers (defined as driving at least once per week) who had completed a baseline MMSE.
Measurements
Involvement in a MVC as the driver.
Results
Baseline MMSE score was divided into four categories: 30, 27–29, 24–26, and < 24. The median MMSE score was 29 (interquartile range 27–30), and 726 (4.1%) has a MMSE score of less than 24 at baseline. After a mean follow‐up of 4.5 years, 1,068 (6.1%) participants were drivers in a MVC. Lower scores were not associated with future MVCs (MMSE score 29–27, hazard ratio (HR) = 1.06, 95% confidence interval (CI) = 0.93–1.22); MMSE score 26–24, HR = 0.96, 95% CI = 0.78–1.19; MMSE score <24, HR = 0.72, 95% CI = 0.50–1.05) on multivariable analysis. A MVC within the previous 2 years (HR = 2.68, 95% CI = 2.29–3.13) was the strongest predictor of future MVCs. Other clinical factors associated with greater MVC risk were depression, falls within the previous year, sleep apnea, and lower baseline systolic blood pressure.
Conclusion
In a population of frequent drivers, the MMSE does not predict MVCs. Other clinical factors have a stronger association with MVC risk.
While lifestyle risk factors are implicated in the development and progression of cognitive impairment, interventional trials of individual participants have yielded unconvincing evidence. We sought ...to explore the development of lifestyle interventions targeting the household-unit.
Semi-structured interviews were carried out among eight households affected by cognitive impairment (i.e. member of the household had cognitive impairment). Interviews took place online using a secure, web-based video platform recommended for patient clinician interaction. Interview content was analysed, and important themes identified.
Eighteen participants were interviewed within households, of which eight (one per household) had cognitive impairment and others were spouses or first-degree relatives living in the same home. Several themes emerged; 1) household members without cognitive impairment were more likely to report poor sleep habits, and sleep was perceived to be the hardest behaviour to change; 2) diet generated most interest as a potential lifestyle intervention target as most participants believed there is a strong link with nutrition and cognition; 3) physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired. Barriers to study participation, including risk of harm, complexity of intervention and deviation from routine emerged during discussions.
This study identified beliefs and preferences of households towards lifestyle intervention trials. Findings from this study may be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.
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