OBJECTIVEThe extent of target organ damage has been associated with both central hemodynamics and arterial stiffening, and the time rate of blood pressure (BP) changes in essential hypertension. ...However, the relative significance of these parameters has not been examined.
METHODSWe recruited 232 consecutive uncomplicated newly diagnosed hypertensive patients and 241 normotensive individuals. Twenty-four-hour ambulatory BP monitoring was performed in all individuals. The time rate of SBP variation was computed as the first derivative of the SBP values against time. Aortic central SBP and central DBP, central pulse pressure, central augmentation index and central augmentation pressure were assessed noninvasively by pulse wave analysis. Common carotid artery intima–media thickness was measured by high-resolution ultrasonography.
RESULTSMedian 24-h time rate of BP changes was 0.571 ± 0.114 mmHg/min. Traditional risk factors, office SBP, several ambulatory BP monitoring parameters (24-h SBP, 24-h pulse pressure, 24-h heart rate and BP dipping), 24-h time rate of BP changes, time rate of BP changes at different time intervals, and central SBP, central pulse pressure, central augmentation index and central augmentation pressure significantly correlated with intima–media thickness. Age, sex, BMI, 24-h time rate of BP changes, time rate of BP changes measured at 0100–0600 h and 24-h heart rate remained significant associates of intima–media thickness after adjustment for confounding factors. By multivariate stepwise linear regression, 24-h time rate of BP changes and time rate of BP changes at 0100–0600 h had incremental value over traditional risk factors, other ambulatory BP monitoring parameters and central hemodynamics.
CONCLUSIONThese findings indicate that time rate of BP variation is superior to central hemodynamics as an associate of carotid intima–media thickness in hypertensive and normotensive individuals.
Objective. Essential hypertension is associated with reduced pain sensitivity of unclear aetiology. This study explores this issue using the Cold Pressor Test (CPT), a reliable pain/stress model, ...comparing CPT-related EEG activity in first episode hypertensives and controls. Method. 22 untreated hypertensives and 18 matched normotensives underwent 24-hour ambulatory blood pressure monitoring (ABPM). EEG recordings were taken before, during, and after CPT exposure. Results. Significant group differences in CPT-induced EEG oscillations were covaried with the most robust cardiovascular differentiators by means of a Canonical Analysis. Positive correlations were noted between ABPM variables and Delta (1–4 Hz) oscillations during the tolerance phase; in high-alpha (10–12 Hz) oscillations during the stress unit and posttest phase; and in low-alpha (8–10 Hz) oscillations during CPT phases overall. Negative correlations were found between ABPM variables and Beta2 oscillations (16.5–20 Hz) during the posttest phase and Gamma (28.5–45 Hz) oscillations during the CPT phases overall. These relationships were localised at several sites across the cerebral hemispheres with predominance in the right hemisphere and left frontal lobe. Conclusions. These findings provide a starting point for increasing our understanding of the complex relationships between cerebral activation and cardiovascular functioning involved in regulating blood pressure changes.
BACKGROUND AND PURPOSE—Information about outcomes in Embolic Stroke of Undetermined Source (ESUS) patients is unavailable. This study provides a detailed analysis of outcomes of a large ESUS ...population.
METHODS—Data set was derived from the Athens Stroke Registry. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group criteria. End points were mortality, stroke recurrence, functional outcome, and a composite cardiovascular end point comprising recurrent stroke, myocardial infarction, aortic aneurysm rupture, systemic embolism, or sudden cardiac death. We performed Kaplan–Meier analyses to estimate cumulative probabilities of outcomes by stroke type and Cox-regression to investigate whether stroke type was outcome predictor.
RESULTS—2731 patients were followed-up for a mean of 30.5±24.1months. There were 73 (26.5%) deaths, 60 (21.8%) recurrences, and 78 (28.4%) composite cardiovascular end points in the 275 ESUS patients. The cumulative probability of survival in ESUS was 65.6% (95% confidence intervals CI, 58.9%–72.2%), significantly higher compared with cardioembolic stroke (38.8%, 95% CI, 34.9%–42.7%). The cumulative probability of stroke recurrence in ESUS was 29.0% (95% CI, 22.3%–35.7%), similar to cardioembolic strokes (26.8%, 95% CI, 22.1%–31.5%), but significantly higher compared with all types of noncardioembolic stroke. One hundred seventy-two (62.5%) ESUS patients had favorable functional outcome compared with 280 (32.2%) in cardioembolic and 303 (60.9%) in large-artery atherosclerotic. ESUS patients had similar risk of composite cardiovascular end point as all other stroke types, with the exception of lacunar strokes, which had significantly lower risk (adjusted hazard ratio, 0.70 95% CI, 0.52–0.94).
CONCLUSIONS—Long-term mortality risk in ESUS is lower compared with cardioembolic strokes, despite similar rates of recurrence and composite cardiovascular end point. Recurrent stroke risk is higher in ESUS than in noncardioembolic strokes.
OBJECTIVETo investigate the association between the presence of ipsilateral nonstenotic carotid plaques and the rate of detection of atrial fibrillation (AF) during follow-up in patients with embolic ...strokes of undetermined source (ESUS).
METHODSWe pooled data of all consecutive ESUS patients from 3 prospective stroke registries. Multivariate stepwise regression assessed the association between the presence of nonstenotic carotid plaques and AF detection. The 10-year cumulative probabilities of AF detection were estimated by the Kaplan-Meier product limit method.
RESULTSAmong 777 patients followed for 2,642 patient-years, 341 (38.6%) patients had an ipsilateral nonstenotic carotid plaque. AF was detected in 112 (14.4%) patients in the overall population during follow-up. The overall rate of AF detection was 8.5% in patients with nonstenotic carotid plaques (2.9% per 100 patient-years) and 19.0% in patients without (5.0% per 100 patient-years) (unadjusted hazard ratio HR 0.56, 95% confidence interval CI 0.37–0.84). The presence of ipsilateral nonstenotic carotid plaques was associated with lower probability for AF detection (adjusted HR 0.57, 95% CI 0.34–0.96, p = 0.03). The 10-year cumulative probability of AF detection was lower in patients with ipsilateral nonstenotic carotid plaques compared to those without (34.5%, 95% CI 21.8–47.2 vs 49.0%, 95% CI 40.4–57.6 respectively, log-rank-test11.8, p = 0.001).
CONCLUSIONSAF is less frequently detected in ESUS patients with nonstenotic carotid plaques compared to those without.
CLINICALTRIALS.GOV IDENTIFIERNCT02766205.
Our objective was to associate serum levels of myocardial enzymes and inflammatory biomarkers with severity of coronary artery disease (CAD).
123 patients participated in our study, including 65 ...cases of acute myocardial infarction (MI), 27 cases of newly diagnosed CAD--without MI--and 31 controls. In all subjects, myocardial serum enzyme levels (creatine phosphokinase, aspartate aminotransferase, lactate dehydrogenase) and inflammatory indices (C-reactive protein, fibrinogen, white blood cells, and erythrocyte sedimentation rate) were measured. Patients were all submitted to coronary angiography and CAD severity was evaluated by Gensini score.
Significant differences concerning enzyme serum levels and inflammatory indices were found to exist between the three study groups, being highest among patients with acute MI (p < 0.001). A significant association was demonstrated between Gensini score and serum enzyme levels as well as inflammatory biomarkers.
Our findings suggest that serum levels of myocardial enzymes and inflammatory indices correlate with CAD severity in Greek patients.
Objective. Thyroid-stimulating-hormone (TSH) receptors are expressed in endothelial cells. We investigated whether elevated TSH levels after acute recombinant TSH (rhTSH) administration may result in ...alterations in blood pressure (BP) in premenopausal women with well-differentiated thyroid carcinoma (DTC). Designs. Thirty euthyroid DTC female patients were evaluated by rhTSH stimulation test (mean age 40.4±8.6 years). A 24 h ambulatory systolic and diastolic blood pressure (SBP, DBP) monitoring (24 hr ABPM) was performed on days 2-3(D2-3). TSH was measured on day 1(D1), day 3(D3), and day 5(D5). Central blood pressure was evaluated on D3. Twenty-three patients were studied 1–4 weeks earlier (basal measurements). Results. TSH levels were D1: median 0.2 mU/L, D3: median 115.0 mU/L, and D5: median 14.6 mU/L. There were no significant associations between TSH on D1 and D3 and any BP measurements. Median D5 office-SBP and 24 h SBP, DBP, and central SBP were correlated with D5-TSH (P<0.04). In those where a basal 24 h ABPM had been performed median pulse pressure was higher after rhTSH-test (P=0.02). Conclusions. TSH, when acutely elevated, may slightly increase SBP, DBP, and central SBP. This agrees with previous reports showing positive associations of BP with TSH.
BACKGROUND AND PURPOSE—Emboli in embolic stroke of undetermined source (ESUS) may originate from various potential embolic sources (PES), some of which may respond better to anticoagulation, whereas ...others to antiplatelets. We analyzed whether rivaroxaban is associated with reduction of recurrent stroke compared with aspirin in patients with ESUS across different PES and by number of PES.
METHODS—We assessed the presence/absence of each PES (atrial cardiopathy, atrial fibrillation, arterial atherosclerosis, left ventricular dysfunction, cardiac valvulopathy, patent foramen ovale, cancer) in NAVIGATE-ESUS (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source) participants. Prevalence of each PES, as well as treatment effect and risk of event for each PES were determined. Results by number of PES were also determined. The outcomes were ischemic stroke, all-cause mortality, cardiovascular mortality, and myocardial infarction.
RESULTS—In 7213 patients (38% women, mean age 67years) followed for a median of 11 months, the 3 most prevalent PES were atrial cardiopathy (37%), left ventricular disease (36%), and arterial atherosclerosis (29%). Forty-one percent of all patients had multiple PES, with 15% having ≥3 PES. None or a single PES was present in 23% and 36%, respectively. Recurrent ischemic stroke risk was similar for rivaroxaban- and aspirin-assigned patients for each PES, except for those with cardiac valvular disease which was marginally higher in rivaroxaban-assigned patients (hazard ratio, 1.8 95% CI, 1.0–3.0). All-cause mortality risks were similar across treatment groups for each PES while too few myocardial infarctions and cardiovascular deaths occurred for meaningful assessment. Increasing number of PES was not associated with increased stroke recurrence nor all-cause mortality, and outcomes did not vary between rivaroxaban- and aspirin-assigned patients by number of PES.
CONCLUSIONS—A large proportion of patients with ESUS had multiple PES which could explain the neutral results of NAVIGATE-ESUS. Recurrence rates between rivaroxaban- and aspirin-assigned patients were similar across the spectrum of PES.
REGISTRATION—URLhttps://www.clinicaltrials.gov; Unique identifierNCT02313909.
BACKGROUND AND PURPOSE—The HAVOC score (hypertension, age, valvular heart disease, peripheral vascular disease, obesity, congestive heart failure, coronary artery disease) was proposed for the ...prediction of atrial fibrillation (AF) after cryptogenic stroke. It showed good model discrimination (area under the curve, 0.77). Only 2.5% of patients with a low-risk HAVOC score (ie, 0–4) were diagnosed with new incident AF. We aimed to assess its performance in an external cohort of patients with embolic stroke of undetermined source.
METHODS—In the AF-embolic stroke of undetermined source dataset, we assessed the discriminatory power, calibration, specificity, negative predictive value, and accuracy of the HAVOC score to predict new incident AF. Patients with a HAVOC score of 0 to 4 were considered as low-risk, as proposed in its original publication.
RESULTS—In 658 embolic stroke of undetermined source patients (median age, 67 years; 44% women), the median HAVOC score was 2 (interquartile range, 3). There were 540 (82%) patients with a HAVOC score of 0 to 4 and 118 (18%) with a score of ≥5. New incident AF was diagnosed in 95 (14.4%) patients (28.8% among patients with HAVOC score ≥5 and 11.3% among patients with HAVOC score 0–4 age- and sex-adjusted odds ratio, 2.29 (95% CI, 1.37–3.82)). The specificity of low-risk HAVOC score to identify patients without new incident AF was 88.7%. The negative predictive value of low-risk HAVOC score was 85.1%. The accuracy was 78.0%, and the area under the curve was 68.7% (95% CI, 62.1%–73.3%).
CONCLUSIONS—The previously reported low rate of AF among embolic stroke of undetermined source patients with low-risk HAVOC score was not confirmed in our cohort. Further assessment of the HAVOC score is warranted before it is routinely implemented in clinical practice.
Background: A simple score was proposed recently for Predicting Early Mortality from Ischemic Stroke (PREMISE) derived from the Austrian Stroke Unit Registry. This score could be useful in clinical ...practice and research. However, its generalizability is uncertain, as it was validated internally only. Aims: We aimed to validate the PREMISE score externally. Methods: The analysis was performed in the Athens Stroke Registry. The PREMISE score was calculated as described in the original publication. The outcome was death within 7 days after stroke. Logistic regression analysis was used to estimate the relative death risk in different strata of the PREMISE score using the lowest values of the score (ie, 0-4) as the reference category. We assessed the score's calibration by the Hosmer-Lemeshow goodness-of-fit test and its discriminatory power by calculating the area under the receiver operating characteristics curve (AUC). Results: In 2608 consecutive patients (median age 71 years, 38.8% women) with acute ischemic stroke treated in the stroke unit, mortality increased with increasing PREMISE score from .1% (95% confidence intervals 95% CI: 0%-.2%) in patients with a score of 0-4 to 28.2% (95% CI: 14.1%-42.3%) in patients with a score of ≥10. The risk for death was more than 6 times higher in patients with a PREMISE score of ≥10 compared to patients with 0-4 points (odds ratio OR:6.21, 95% CI:4.13-8.29). Τhe PREMISE score showed excellent calibration (Hosmer-Lemeshow χ2: .01, P= .99) and good discriminatory power (AUC .873, 95% CI: .844-.901). Conclusions: The present study confirms the prognostic accuracy of the PREMISE score in an independent cohort of patients with acute ischemic stroke treated in the stroke unit.
•LAD is related with new incidental AF after ESUS.•LAD threshold of 40 mm has the best performance to predict incident AF after ESUS.•ESUS patients with LAD ≤ 40 mm may have lower priority for ...prolonged rhythm monitoring.
We analyzed consecutive patients with embolic stroke of undetermined source (ESUS) from three prospective stroke registries to compare the prognostic performance of different LAD thresholds for the prediction of new incident AF.
We calculated the sensitivity, specificity, positive prognostic value (PPV), negative prognostic value (NPV) and Youden's J-statistic of different LAD thresholds to predict new incident AF. We performed multivariate stepwise regression with forward selection of covariates to assess the association between the LAD threshold with the highest Youden's J-statistic and AF detection.
Among 675 patients followed for 2437 patient-years, the mean LAD was 38.5 ± 6.8 mm. New incident AF was diagnosed in 115 (17.0%) patients. The LAD threshold of 40mm yielded the highest Youden's J-statistic of 0.35 with sensitivity 0.69, specificity 0.66, PPV 0.27 and NPV 0.92. The likelihood of new incident AF was nearly twice in patients with LAD > 40 mm compared to LAD ≤ 40 mm (HR:1.92, 95%CI:1.24–2.97, p = 0.004). The 10-year cumulative probability of new incident AF was higher in patients with LAD>40 mm compared to LAD ≤ 40 mm (53.5% and 22.4% respectively, log-rank-test: 28.2, p < 0.001). The annualized rate of stroke recurrence of 4.0% in the overall population did not differ significantly in patient above vs. below this LAD threshold (HR:0.96, 95%CI:0.62–1.48, p = 0.85).
The LAD threshold of 40 mm has the best prognostic performance among other LAD values to predict new incident AF after ESUS. The diagnostic yield of prolonged cardiac rhythm monitoring in patients with LAD ≤ 40 mm seems low; therefore, such patients may have lower priority for prolonged cardiac monitoring.
PDF
