Background:Guidelines for peripheral arterial disease (PAD) recommend long-term antiplatelet therapy in symptomatic patients to reduce cardiovascular morbidity and mortality risk. Although diabetes ...is a known risk factor for PAD, PAD has been undertreated in these patients. This study aimed to evaluate risk factors for major amputation in patients with diabetes undergoing antiplatelet therapy for PAD.Methods and Results:This retrospective analysis of a 2-year observational cohort study (1,745 clinics in Japan, September 2009–2013) evaluated predictors of amputation in patients with diabetes undergoing antiplatelet therapy for PAD. Among 4,016 eligible patients, 52 had an amputation during follow-up. Amputation risk (Cox regression analysis) was predicted at baseline by history of lower extremity revascularization/amputation (hazard ratio HR: 2.92; 95% confidence interval CI: 1.39, 6.14), chronic kidney disease (HR: 4.19; 95% CI: 1.95, 8.97), and comorbid cerebrovascular and heart disease (HR: 3.32; 95% CI: 1.19, 9.30), and was unaffected by choice of oral antiplatelet therapy. In patients with PAD and diabetes, amputation event rate was highest for those with ankle-brachial pressure index (ABI) <0.40 and progressively decreased at higher ABI cut-offs.Conclusions:These findings inform real-world understanding of PAD in diabetic patients receiving antiplatelet therapy in Japan, and showed that ABI <0.4 was the strongest risk factor for amputation.
Objective
Takotsubo cardiomyopathy, which is characterized by transient left ventricular apical ballooning, is a known complication of subarachnoid hemorrhage. The aim of this study was to identify ...the clinical characteristics of acute ischemic stroke patients who experienced development of takotsubo cardiomyopathy.
Methods
Seven patients who were diagnosed as having takotsubo cardiomyopathy based on their electrocardiographic and echocardiographic findings were studied. They were selected from among 569 consecutive patients who were admitted to our stroke center within 24 hours after onset of acute ischemic stroke. The findings of nine previously published cases were also reviewed.
Results
All seven patients were women, and six were 75 years or older. The initial National Institutes of Health Stroke Scale score ranged from 3 to 28. The culprit infarcts included or were close to the insular cortex in six patients and were located extensively in the vertebrobasilar arterial territory in the other patient. Abnormal findings on electrocardiographic monitoring appeared within 10 hours after stroke onset in five patients and at 6 and 12 days, respectively, in the other two patients. The cardiomyopathy was symptomatic in only two patients. Plasma brain natriuretic peptide levels exceeded the upper normal limit by 10‐fold in all patients. The previously published cases were mostly women and had mainly vertebrobasilar stroke.
Interpretation
Takotsubo cardiomyopathy is not a rare complication of acute ischemic stroke. It most often occurred soon after stroke onset and was commonly asymptomatic. Female sex and insular damage were predominant features of the stroke patients who experienced development of takotsubo cardiomyopathy. Ann Neurol 2008
Background:Despite mounting evidence of increased cardiovascular events in patients with peripheral arterial disease (PAD), the overall incidence of cardiovascular events in PAD patients has not been ...fully clarified in Japan. The prospective Surveillance of cardiovascular Events in Antiplatelet-treated arterioSclerosis Obliterans patients in JapaN (SEASON) is a prospective observational multicenter study and here we report the baseline clinical characteristics, including atherosclerosis risk factor prevalence, in PAD patients treated with antiplatelet agents.Methods and Results:The SEASON registry enrolled 11,375 patients in 1,745 institutions and the data for 10,322 patients were analyzed. At baseline, the average age was 73.8±9.9 years, 60.0% were male and 83.9% were in Fontaine stage I or II. They had arteriosclerosis risk factors, such as current smoking (16.2%), hypertension (61.5%), diabetes mellitus (38.3%) and dyslipidemia (38.8%). There were complications including heart disease (29.7%), cerebrovascular disease (17.1%) and chronic kidney disease (14.3%). A subpopulation analysis revealed that the proportions of patients with risk factors were high in patients with lower ankle-brachial pressure index value.Conclusions:The baseline characteristics of the SEASON population demonstrate that real-world PAD patients have cardiovascular risk factors and comorbidities next to definite PAD patients. Further analysis of this database will contribute to understanding the real-world situation of PAD patients receiving antiplatelet therapy in Japan. (Circ J 2016; 80: 712–721)
The mechanism of motor recovery after stroke may involve reorganization of the surviving networks. However, details of adaptive changes in structural connectivity are not well understood. Here, we ...show long-term changes in white matter microstructure that relate to motor recovery in stroke patients. We studied ten subcortical ischemic stroke patients who showed motor hemiparesis at the initial clinical examination and an infarcted lesion centered in the posterior limb of internal capsule of the unilateral hemisphere at the initial diffusion-weighted magnetic resonance imaging scan. The participants underwent serial diffusion tensor imaging and motor function assessments at three consecutive time points; within 2 weeks, and at 1 and 3 months after the onset. Fractional anisotropy (FA) was analyzed for regional differences between hemispheres and time points, as well as for correlation with motor recovery using a tract-based spatial statistics analysis. The results showed significantly increased FA in the red nucleus and dorsal pons in the ipsi-lesional side at 3 months, and significantly decreased FA in the ipsi-lesional internal capsule at all time points, and in the cerebral peduncle, corona radiata, and corpus callosum at 3 months. In the correlation analysis, FA values of clusters in the red nucleus, dorsal pons, midbody of corpus callosum, and cingulum were positively correlated with recovery of motor function. Our study suggests that changes in white matter microstructure in alternative descending motor tracts including the rubro-spinal pathway, and interhemispheric callosal connections may play a key role in compensating for motor impairment after subcortical stroke.
The present analysis was intended to evaluate the real-world management of peripheral arterial disease (PAD) in Asia, and to explore cardiovascular events in patients with PAD undergoing antiplatelet ...therapy over 2 years of follow-up. The Surveillance of cardiovascular Events in Antiplatelet-treated arteriosclerosis Obliterans patients in JapaN (SEASON) registry is a prospective observational multicenter study of cardiovascular events in antiplatelet-treated patients with PAD in Japan. The SEASON registry included 11,375 patients who were scheduled to receive treatment for PAD. Two analysis populations were defined: a real-world population (RWP; n = 10,322) and a definite PAD population (DPP; n = 3992) who had ankle-brachial pressure index (ABPI) <0.9 and intermittent claudication, or a history of lower limb revascularization. The primary outcome measure was the rate of the composite of cerebrovascular, cardiovascular, and peripheral vascular events. The composite event rates (95% confidence interval) were 3.28 (3.00-3.57) and 5.71 (5.13-6.34) events per 100 patient-years in the RWP and DPP groups, respectively. Fontaine IV classification and ABPI <0.4 at baseline were both identified as strong risk factors for vascular events. These findings contribute to understanding the situation for real-world patients with PAD receiving antiplatelet therapy.
Background: Patients in rehabilitation facility have enormously long free time and often fall asleep during daytime. Excessive daytime sleep (DS) was reported to decrease rehabilitation efficiency ...resulting in poor functional recovery. In general population, insomnia, obesity, depression, dementia and the use of sleeping pills are known to be important risk factors of excessive DS. However, the causes of excessive daytime sleep in patients undergoing inpatient rehabilitation have not been clearly identified. Therefore, the current preliminary study aimed to explore factors underlying excessive DS in elderly patients undergoing inpatient rehabilitation following acute stroke. Methods: Subjects were 17 patients without dementia with more than 65 years of age who were admitted to our rehabilitation wards following acute stroke. In all the patients, daytime and nighttime sleep states were monitored with wrist actigraphy consecutively for five days. Relationships of DS duration with insomnia, obesity, depression, apathy, hypnotic administration, motor functional ability, recreational activities and self-exercise were investigated. Results: All the patients had more or less DS, the duration of which widely ranged from 43 to 550 min/day with mean value 210 ± 122 min/day. This DS duration was 3 - 4 times longer than that in general elderly population. The majority of patients had sufficiently long nighttime sleep (NS). There was no correlation between DS duration and NS duration. DS duration had no relationship with obesity, depression, apathy, hypnotic administrations, or motor functional ability. DS duration was, however, significantly shorter in patients performing self-exercise (n = 10, 157 ± 82 min) than in those without self-exercise (n = 7, 285 ± 135 min) (p = 0.03). Recreational activities did not shorten DS duration.Conclusion: Patients in rehabilitation facility tend to have long DS because of enormously long free time and consequent idleness. Taking up the free time with self-exercise appears to be useful for preventing excessive DS.
Objective
This study was designed to determine the histopathological characteristics of cardiac and vascular lesions responsible for various subtypes of ischemic stroke.
Methods
Postmortem ...pathological examination was performed on 142 patients who died within 30 days of the onset of ischemic stroke in the National Cardiovascular Center, Osaka, Japan.
Results
The numbers of cases with autopsy‐proven diagnoses of atherothrombotic, cardioembolic, and lacunar strokes, ischemic stroke of other determined causes, and ischemic stroke of undetermined cause were 17, 107, 2, 12, and 4, respectively. Thrombi that developed at the culprit plaques of the cerebral arteries were responsible for atherothrombotic stroke. In 70% of the cases with cardioembolic stroke, the presence of thrombi as potential embolic sources were confirmed in the heart or, in some cases, in the venous circulation of patients with patent foramen ovale and tetralogy of Fallot.
Interpretation
In most atherothrombotic strokes, fibrin‐ and platelet‐rich thrombi of various thicknesses develop at the culprit plaques of the cerebral arteries, which are finally occluded with fibrin‐ and red‐cell–rich thrombi (red thrombi). In most cardioembolic strokes, red thrombi generated in the heart or peripheral veins are dislodged to embolize the cerebral arteries. Ann Neurol 2008
The aim of this study was to analyze the causes and outcomes for intracerebral hemorrhage (ICH) occurring during pregnancy and postnatally.
A nationwide study of pregnancy-related ICH in Japan was ...performed. We contacted 1582 facilities to identify women with ICH in pregnancy or postnatally between 1 January 2006 and 31 December 2006. A total of 1012 facilities (70%) responded with completed questionnaires. Risk factors for ICH, neurological features, onset to diagnosis time (O-D time), and obstetric data were recorded.
Thirty-eight cases of pregnancy-associated ICH were identified, corresponding to 3.5 per 100 000 deliveries. There were seven maternal deaths, giving a case mortality rate of 18.4%. Pre-eclampsia was identified in 10 cases (26.3%) and hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome was present in five. There were four cases (10.5%) with Moyamoya disease and seven (18.4%) with arteriovenous malformation. HELLP syndrome and moderately or severely disturbed consciousness at disease onset were significantly associated with a poor outcome (modified Rankin Scale ≥3). Pre-eclampsia, HELLP syndrome and O-D time >3 h were significantly associated with maternal mortality.
Early diagnosis may prevent maternal death, even in severe cases of pregnancy-related ICH. However, maternal-fetal care centers do not always have full-time neurosurgeons or diagnostic imaging tools suitable for diagnosis of ICH. Thus, a network should be established between maternity centers and neurosurgery departments with computed tomography or magnetic resonance imaging available at all times. We recommend transferal of pregnant women with neurological symptoms to a regional facility that is equipped to treat such patients.
High serum uric acid level (SUA) and chronic kidney disease (CKD) are risk factors for cardiovascular events (CVEs). However, their interactions as cardiovascular risk factors remain unknown. This ...subanalysis of the Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH) study included 7629 patients, in whom the serum creatinine level was measured at least twice. The study examined the impact of hyperuricemia (SUA ≥7 mg dl(-1)) on CVE according to the level of renal dysfunction and whether early changes in SUA predicted future glomerular filtration rates (GFRs). The mean follow-up period was 3.1 years. The patients were divided into three groups according to the baseline estimated GFR (eGFR): groups A, B and C with eGFR <45, 45-59 and ≥60 ml min(-1) per 1.73 m(2), respectively. eGFR increased from 38.1 to 57.6, from 52.8 to 67.5 and from 74.7 to 80.7 ml min(-1) per 1.73 m(2) in groups A, B and C, respectively. In non-hyperuricemic patients, the CVE rate was 10.83, 4.98 and 4.21/1000 person-years in groups A, B and C, respectively, while in hyperuricemic patients, the corresponding values were 14.18, 17.02 and 5.93. Thus, hyperuricemia increased the risk of CVE only in group B (relative risk (RR) 3.43 (95% confidence interval (CI) 1.55 to 7.60); P<0.002). The final change in the eGFR was negatively correlated with the change in SUA from baseline to year 1 (P<0.001). CVEs were more frequent in those with a decrease in eGFR. Hyperuricemia may be a major determinant of increased cardiovascular risk in CKD stage 3A, and SUA may be involved in the progression of CKD. Changes in the GFR influence the rate of CVE.
PDF
