Several clinical trials have provided evidence supporting the transcatheter closure of patent foramen ovale (PFO) in selected patients following a cryptogenic stroke. However, it remains unknown to ...what extent these guidelines have been implemented in everyday clinical practice and the familiarity of physicians from different specialties with PFO closure. The aim of our nationwide survey is to explore the implementation of transcatheter PFO occlusion in Greek clinical practice.
Attending level cardiologists, internal medicine physicians and neurologists involved in the management of PFO-related strokes working in Greece were invited to complete an online questionnaire. The questionnaire consisted of 19 questions and was designed to obtain comprehensive data on provider demographics, PFO characteristics, and specific clinical scenarios.
A total of 51 physicians (56.9 % cardiologists, 25.5 % neurologists and 17.6 % internal medicine physicians) completed the survey, resulting in a response rate of 53 %. Cardiologists, internal medicine physicians and neurologists agree on several issues regarding PFO closure, such as PFO closure as first line treatment, management of patients with DVT or prior decompression sickness, and post-closure antithrombotic treatment, but different approaches were reported regarding closure in patients with thrombophilia treated with oral anticoagulation (p=0.012) and implantable loop recorder placement for atrial fibrillation exclusion (p=0.029 and p=0.020).
Our findings show that cardiologists, internal medicine physicians and neurologists agree in numerous issues, but share different views in the management of patients with thrombophilia and rhythm monitoring duration. These results highlight the significance of collaboration among physicians from different medical specialties for achieving optimal results.
Summary of main findings of Greek survey about Patent Foramen Ovale (PFO) closure. Display omitted
Background: The diagnosis of covert atrial fibrillation (AF) remains a major challenge to guide secondary prevention of patients with embolic stroke of undetermined source (ESUS). Aims: We analyzed ...consecutive ESUS patients from 3 prospective stroke registries to assess whether the presence of supraventricular extrasystoles (SVE) on standard 12-lead electrocardiogram (ECG) is associated with the detection of AF (primary outcome), stroke recurrence and death (secondary outcomes) during follow-up. Methods: We measured the number of SVEs in all available ECGs of patients hospitalized for ESUS. Multivariate stepwise regression with forward selection of covariates assessed the association between SVE (classified in 4 groups according to their number per 10 seconds of ECG: no SVE, >0-1SVEs, >1-2SVEs, and >2SVEs) and outcomes during follow-up. The Kaplan–Meier product limit method estimated the 10-year cumulative probabilities of outcomes in each SVE group. We calculated the negative prognostic value (NPV) of the presence of any SVE to predict new AF, defined as the probability that AF will not be detected during follow-up if there is no SVE. Results: Among 853 ESUS patients followed for 2857 patient-years (median age: 67 years, 43.0% women), 226 (26.5%) patients had at least 1 SVE at the standard 12-lead ECGs performed during hospitalization. AF was detected in 125 (14.7%) of patients in the overall population during follow-up: 8.9%, 22.5%, 28.1%, and 48.3% in patients with no SVE, greater than 0-1SVE, greater than 1-2SVE and greater than 2SVE respectively. In multivariate regression analysis, compared to patients with no SVEs, the corresponding hazard-ratios were 1.80 95% confidence intervals (95%CI):1.06-3.05, 2.26 (95%CI:1.28-4.01) and 3.19 (95%CI:1.93-5.27). The NPV of the presence of any SVE for the prediction of new AF was 91.4%. There was no statistically significant association of SVE with the risk of ischemic stroke recurrence and death. Conclusions: In ESUS patients without SVEs during hospitalization, the probability that AF will not be detected during a follow-up of 3.4 years is more than 91%.
OBJECTIVE:To investigate whether the correlation of age and sex with the risk of recurrence and death seen in patients with previous ischemic stroke is also evident in patients with embolic stroke of ...undetermined source (ESUS).
METHODS:We pooled datasets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. We performed Cox regression and Kaplan-Meier product limit analyses to investigate whether age (<60, 60–80, >80 years) and sex were independently associated with the risk for ischemic stroke/TIA recurrence or death.
RESULTS:Ischemic stroke/TIA recurrences and deaths per 100 patient-years were 2.46 and 1.01 in patients <60 years old, 5.76 and 5.23 in patients 60 to 80 years old, 7.88 and 11.58 in those >80 years old, 3.53 and 3.48 in women, and 4.49 and 3.98 in men, respectively. Female sex was not associated with increased risk for recurrent ischemic stroke/TIA (hazard ratio HR 1.15, 95% confidence interval CI 0.84–1.58) or death (HR 1.35, 95% CI 0.97–1.86). Compared with the group <60 years old, the 60- to 80- and >80-year groups had higher 10-year cumulative probability of recurrent ischemic stroke/TIA (14.0%, 47.9%, and 37.0%, respectively, p < 0.001) and death (6.4%, 40.6%, and 100%, respectively, p < 0.001) and higher risk for recurrent ischemic stroke/TIA (HR 1.90, 95% CI 1.21–2.98 and HR 2.71, 95% CI 1.57–4.70, respectively) and death (HR 4.43, 95% CI 2.32–8.44 and HR 8.01, 95% CI 3.98–16.10, respectively).
CONCLUSIONS:Age, but not sex, is a strong predictor of stroke recurrence and death in ESUS. The risk is ≈3- and 8-fold higher in patients >80 years compared with those <60 years of age, respectively. The age distribution in the ongoing ESUS trials may potentially influence their power to detect a significant treatment association.
BACKGROUND AND PURPOSE—The risk of stroke recurrence in patients with Embolic Stroke of Undetermined Source (ESUS) is high, and the optimal antithrombotic strategy for secondary prevention is ...unclear. We investigated whether congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or transient ischemic attack (TIA; CHADS2) and CHA2DS2-VASc scores can stratify the long-term risk of ischemic stroke/TIA recurrence and death in ESUS.
METHODS—We pooled data sets of 11 stroke registries from Europe and America. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group. Cox regression analyses were performed to investigate if prestroke CHADS2 and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65–74 years, sex category (CHA2DS2-VASc) scores were independently associated with the risk of ischemic stroke/TIA recurrence or death. The Kaplan–Meier product limit method was used to estimate the cumulative probability of ischemic stroke/TIA recurrence and death in different strata of the CHADS2 and CHA2DS2-VASc scores.
RESULTS—One hundred fifty-nine (5.6% per year) ischemic stroke/TIA recurrences and 148 (5.2% per year) deaths occurred in 1095 patients (median age, 68 years) followed-up for a median of 31 months. Compared with CHADS2 score 0, patients with CHADS2 score 1 and CHADS2 score >1 had higher risk of ischemic stroke/TIA recurrence (hazard ratio HR, 2.38; 95% confidence interval CI, 1.41–4.00 and HR, 2.72; 95% CI, 1.68–4.40, respectively) and death (HR, 3.58; 95% CI, 1.80–7.12, and HR, 5.45; 95% CI, 2.86–10.40, respectively). Compared with low-risk CHA2DS2-VASc score, patients with high-risk CHA2DS2-VASc score had higher risk of ischemic stroke/TIA recurrence (HR, 3.35; 95% CI, 1.94–5.80) and death (HR, 13.0; 95% CI, 4.7–35.4).
CONCLUSIONS—The risk of recurrent ischemic stroke/TIA and death in ESUS is reliably stratified by CHADS2 and CHA2DS2-VASc scores. Compared with the low-risk group, patients in the high-risk CHA2DS2-VASc group have much higher risk of ischemic stroke recurrence/TIA and death, approximately 3-fold and 13-fold, respectively.
OBJECTIVESThe rate of blood pressure (BP) variation has been positively associated with intima–media thickness of common carotid arteries and left ventricular mass. We evaluated the association ...between the rate of BP variation derived from ambulatory blood pressure monitoring (ABPM) data analysis and impaired renal function.
METHODSTwenty-four-hour ABPM was performed in 803 untreated hypertensive patients. The estimated glomerular filtration rate (eGFR) was assessed using the abbreviated equation of the Modification Diet for Renal Disease study. Patients were divided into two groupsthose with an eGFR less than 60 ml/min per 1.73 m (group A) and those with an eGFR 60 ml/min per 1.73 m or more (group B).
RESULTSThe 24-h rate of systolic BP variation was significantly (P = 0.004) higher in group A 0.616 mmHg/min; 95% confidence interval (CI) 0.596–0.636 than in group B patients (0.585 mmHg/min; 95% CI 0.578–0.591), even after adjusting for baseline characteristics and ABPM parameters. In the entire study population, the multiple logistic regression models revealed the following variables as independent determinants of impaired renal functionage, male sex, office systolic BP and 24-h rate of systolic BP variation. In this model, the odds ratio for impaired renal function associated with each 0.1 mmHg/min increase in 24-h rate of systolic BP variation was 1.49 (95% CI 1.18–1.88, P = 0.001).
CONCLUSIONThe 24-h rate of SBP variation is independently associated with impaired renal function. Target-organ damage in hypertensive patients, in addition to BP levels, dipping status and BP variability, may also be related to a steeper rate of BP fluctuations.
Objective
The importance of abnormalities observed in the microcirculation of patients with arterial hypertension (AH) is being increasingly recognized. The authors aimed to evaluate skeletal muscle ...microcirculation in untreated, newly diagnosed hypertensive patients with NIRS, a noninvasive method that evaluates microcirculation.
Methods
We evaluated 34 subjects, 17 patients with AH (13 males, 49±13 years, BMI: 26±2 kg/m2) and 17 healthy controls (12 males, 49±15 years, BMI: 25±3 kg/m2). The thenar muscle StO2 (%) was measured by NIRS before, during and after 3‐minutes vascular occlusion to calculate OCR (%/min), EF (%/min), and RHT (minute). The dipping status of hypertensive patients was assessed.
Results
The RHT differed between AH patients and healthy subjects (2.6±0.3 vs 2.1±0.3 minutes, P<.001). Dippers had higher EF than nondippers (939±280 vs 710±164%/min, P=.05).
Conclusions
The study suggests an impaired muscle microcirculation in newly diagnosed, untreated AH patients.
Among the physiological variables whose diurnal profile is governed by circadian rhythmicity, plasma glucose concentrations, and arterial blood pressure constitute key elements of the physiological ...regulation of energy homeostasis. Evidence on their diurnal association derived from frequent measurements of both variables is, however, lacking in humans.
We investigated the relationship between blood pressure levels recorded by an ambulatory device and interstitial glucose concentrations on an outpatient basis, in patients with normal glucose tolerance (N=20), either normotensive (group A; N=10), or newly diagnosed with essential hypertension (group B; N=10).
In the population throughout the 24-h monitoring period, there was a significant positive correlation between interstitial glucose concentrations and systolic, diastolic, and mean 24-h blood pressure levels, which was retained in patients with hypertension compared with normotensive patients. In patients with newly diagnosed hypertension, interstitial glucose concentrations exhibit significant correlation to systolic blood pressure levels during the 24-h period, but no association with diastolic and mean blood pressure during the night, whereas the reverse is the case in patients with normal glucose tolerance and normal blood pressure.
Diurnal variations of continuously monitored interstitial glucose concentrations significantly associate with blood pressure levels in both normotensive and hypertensive humans, indicating a common pathway of circadian autoregulation, probably stemming from both central mechanisms and peripheral inputs. Such a pathway might underlie similar pathophysiological aberration in disease states such as the metabolic syndrome.
Background and aims
Patients with embolic strokes of undetermined source (ESUS) usually present with mild symptoms. We aimed to compare the baseline characteristics between mild and severe ESUS, ...identify predictors for severe ESUS, and assess outcomes of patients with severe ESUS.
Methods
In the AF-ESUS (AF-ESUS) dataset, we stratified ESUS severity using the median National Institutes of Health Stroke Scale (NIHSS) score on admission as cut-off. We performed multivariable stepwise regression analyses to identify independent predictors of severe ESUS and to assess the association between ESUS severity and stroke recurrence, death, and new incident atrial fibrillation (AF) on follow-up. The 10-year cumulative probabilities of outcome incidence were estimated by the Kaplan–Meier product limit method.
Results
In 772 patients (median NIHSS: 6 (interquartile range: 3–12)), 414 (53.6%) patients had severe ESUS (i.e. NIHSS ≥6). Female sex was the only independent predictor for severe ESUS (odds ratio: 1.72 (1.27–2.33)). The rates of recurrence (3.3%/year vs. 3.4%/year, adjusted-hazard ratio: 1.09 (0.73–1.62)) and new incident AF (13.5% vs. 17.0%, adjusted odds ratio: 0.67 (0.44–1.03)) were similar between severe and mild ESUS, but mortality was higher (5.4%/year vs. 3.7%/year, adjusted-hazard ratio: 1.51 (1.05–2.16)) in severe ESUS. The 10-year cumulative probability for stroke recurrence was similar between severe and mild ESUS (38.1% (29.2–48.6) vs. 36.6% (27.8–47.0), log-rank test: 0.01, p = 0.920). The 10-year cumulative probability of death was higher in patients with severe ESUS compared with mild ESUS (40.5% (32.5–50.0) vs. 34.0% (26.0–43.6) respectively; log-rank test: 4.54, p = 0.033).
Conclusions
Women have more severe ESUS compared with men. Patients with severe ESUS have similar rates of stroke recurrence and new incident AF, but higher mortality compared with mild ESUS.
Aims
The aim of this study was to investigate stroke aetiology and assess the predictors of early and late outcome in patients with heart failure (HF) and acute stroke.
Methods and results
A total of ...2904 patients, admitted between 1993 and 2010, were regularly followed up at months 1, 3, and 6, and yearly thereafter up to 10 years. There were 283 (9.7%) stroke patients with HF; atrial fibrillation (AF) was present in 144 (50.9%) of them. Stroke aetiology in patients with HF and AF was mainly cardioembolism (82%) regardless of HF aetiology. In contrast, in the 139 non-AF patients with HF, the stroke mechanism was associated with the aetiology of HF: valvular heart disease and dilated cardiomyopathy were related to cardioembolism in 60% and 66.7% of patients, respectively, whereas HF due to coronary artery disease or hypertension was associated with atherosclerotic and lacunar stroke in 40.8% and 61.5%, respectively. In the overall population, HF was an independent predictor of 10-year mortality hazard ratio = 1.54, 95% confidence interval (CI) 1.29-1.83; P < 0.001. Probability of 10-year survival was 19.4% (95% CI 14.5-23.5) for HF patients and 44.1% (95% CI 41.4-46.8) for non-HF patients (P < 0.0001). Ten-year mortality in HF patients was associated with functional class of HF, age, diabetes, stroke severity, and in-hospital aspirin use. The presence of AF in HF stroke patients did not influence 10-year survival and composite cardiovascular events (P = 0.429 and P = 0.406, respectively).
Conclusions
In patients with HF, stroke aetiology is influenced by the presence of AF and the underlying cause of HF. Early and late stroke outcome is associated with HF severity but not with the presence of AF.
OBJECTIVEA tool to stratify the risk of stroke recurrence in patients with embolic stroke of undetermined source (ESUS) could be useful in research and clinical practice. We aimed to determine ...whether a score can be developed and externally validated for the identification of patients with ESUS at high risk for stroke recurrence.
METHODSWe pooled the data of all consecutive patients with ESUS from 11 prospective stroke registries. We performed multivariable Cox regression analysis to identify predictors of stroke recurrence. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score externally assessing its discrimination and calibration.
RESULTSIn 3 registries (884 patients) that were used as the derivation cohort, age, leukoaraiosis, and multiterritorial infarct were identified as independent predictors of stroke recurrence and were included in the final score, which assigns 1 point per every decade after 35 years of age, 2 points for leukoaraiosis, and 3 points for multiterritorial infarcts (acute or old nonlacunar). The rate of stroke recurrence was 2.1 per 100 patient-years (95% confidence interval CI 1.44–3.06) in patients with a score of 0–4 (low risk), 3.74 (95% CI 2.77–5.04) in patients with a score of 5–6 (intermediate risk), and 8.23 (95% CI 5.99–11.3) in patients with a score of 7–12 (high risk). Compared to low-risk patients, the risk of stroke recurrence was significantly higher in intermediate-risk (hazard ratio HR 1.78, 95% CI 1.1–2.88) and high-risk patients (HR 4.67, 95% CI 2.83–7.7). The score was well-calibrated in both derivation and external validation cohorts (8 registries, 820 patients) (Hosmer-Lemeshow test χ12.1 p = 0.357 and χ21.7 p = 0.753, respectively). The area under the curve of the score was 0.63 (95% CI 0.58–0.68) and 0.60 (95% CI 0.54–0.66), respectively.
CONCLUSIONSThe proposed score can assist in the identification of patients with ESUS at high risk for stroke recurrence.
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