Risk factors and ambulatory outcome in ischemic stroke patients with pre-stroke depression

ObjectiveIt is well known that post-stroke depression might be a negative factor for stroke recovery, however there is limited evidence to establish the link between pre-stroke depression and stroke outcome such motor recovery. The objective is to determine clinical risk factors in ischemic stroke patients with pre-stroke depression that are associated functional ambulatory outcome.MethodsData from acute ischemic patients from a regional stroke registry were collected for consecutive recombinant tissue plasminogen activator(rtPA)-treated acute ischemic stroke patients between January 2010 and June 2016. Logistic regression model was used to predict risk factors that served as predictive variables, while the increase or reduce odds of improvement in ambulatory outcome was considered as the primary outcome. Multicollinearity and possible interactions among the independent variables were analyzed using the variance inflation factor.ResultsA total of 1446 patients were eligible for recombinant tissue plasminogen activator (rtPA) and 596 of these patients received rtPA. Of the 596 ischemic stroke patients, 286 patients presented with recent pre-stroke depression, 310 had no pre-stroke depression. Carotid artery stenosis (OR = 11.577, 95% CI, 1.281–104.636, P = 0.029) and peripheral vascular disease (OR = 18.040, 95% CI, 2.956–110.086, P = 0.002) were more likely to be associated with increase odds of improvement in ambulation in patients with no pre-stroke depression treated with rtPA, while antihypertensive medications (OR = 0.192, 95% CI, 0.035–1.067, P = 0.050),previous TIA (OR = 0.177, 95% CI, 0.038–0.818, P = 0.027), and congestive heart failure (OR = 0. 0.160, 95% CI, 0.030–0.846, P = 0.031) were associated with reduced odds of improvement in ambulation. In addition, carotid artery stenosis (OR = 0.078, 95% CI, 0.10-0.614, P = 0.015, congestive heart failure (OR = 0.217, 95% CI, 0.318–0.402, P = 0.030), previous TIA (OR = 0.444, 95% CI, 0.517–0.971, P = 0.012), higher NIHSS scores ((OR = 0.887, 95% CI, 0.830–0.948, P < 0.001), and antihypertensive medications (OR = 0.810, 95% CI, 0.401–0.529, P = 0.019) were associated with the reduced odd of improvement in ambulation in an ischemic stroke population with pre-stroke depression treated with rtPA.ConclusionOur findings indicate that more risk factors were associated with the decreased odds of an improvement in ambulation following thrombolytic therapy in an ischemic stroke population with pre-stroke depression when compared with those without pre-stroke depression. This finding maybe helpful in the development of management strategies to increase the use of thrombolytic therapy for pre-stroke depressed ischemic stroke to increased their eligibility for rtPA.     

Undetermined stroke with an embolic pattern—a common phenotype with high early recurrence risk

Abstract

Introduction. Undetermined strokes with an embolic pattern (USEP) represent a common phenotype. We assessed their frequency and compared USEP with cardioembolic stroke with a known source and non-cardioembolic stroke etiology.

Methods. Study patients were 540 consecutive ischemic stroke patients admitted to Helsinki University Hospital with primary end-point of recurrent stroke in a 21-month follow-up. Cox regression adjusting for CHA₂DS₂-VASc and anticoagulation estimated the risk of USEP on recurrent stroke.

Results. A total of 229 (42.4%) patients had a non-cardioembolic stroke etiology, 184 (34.1%) had a cardioembolic stroke with a known source, and 127 (23.5%) were classified as USEP. USEP patients had less diabetes and prior TIA, with more severe symptoms than the non-cardioembolic stroke cases. They were younger, had fewer comorbidities, and less severe symptoms than the cardioembolic stroke patients. Cumulative risk of recurrent stroke was 10.0% (95% CI 4.1%–15.9%) for USEP, 5.0% (1.1%–8.9%) for cardioembolic strokes, and 5.0% (3.0%–7.0%) for non- cardioembolic strokes (P = 0.089). USEP associated with a higher risk of recurrent stroke compared to non-cardioembolic strokes (hazard ratio 2.36, 95% CI 1.02–5.47; P = 0.046) and cardioembolic stroke with a known source (1.83, 1.07–3.14; P = 0.028).

Conclusions. Despite their younger age and more favorable risk factor profile compared with other phenotypes, USEP exhibited a high risk of stroke recurrence.     

Significant interactions between traditional risk factors affect cardiovascular risk prediction in healthy general population

Abstract

Aims. The aim was to carry out a systematic screening of interactions between the traditional risk factors and to evaluate which interactions are truly relevant for estimation of cardiovascular disease (CVD) risk.

Methods. Cox regression was used in a meta-analysis of five independent, population-based health examination surveys (the National FINRISK Study). End-points were 10-year incidence of coronary heart disease (CHD), ischemic stroke (IS), and CVD in a population free of cardiovascular disease (n = 35,460).

Results. In addition to expected age interactions, systolic blood pressure was found to be a markedly stronger risk factor for CVD (and for CHD) among subjects with normal BMI (BMI < 25: HR 1.42 [1.30–1.55] for one SD increase in systolic blood pressure) when compared to obese subjects (BMI > 30: HR 1.10 [1.01–1.19]) (P < 0.001 for interaction) and among subjects with highest high-density lipoprotein (HDL) (33% tertile: HR 1.43 [1.29–1.58]) when compared to subjects with low HDL (lowest 33% tertile: HR 1.20 [1.13–1.28]) (P < 0.001 for interaction). Interactions improved risk prediction of CVD (cross-validated continuous net reclassification improvement [NRI] 49.4% with 95% CI 44.7%–54.1%, P < 0.0001 and clinical NRI 4.7%, with 95% CI 2.8%–6.5%, P < 0.0001). The C-statistic improved from 0.8438 to 0.8455 (P = 0.010). No significant interaction was associated with the risk of IS.

Conclusions. There are significant effect modifications between major risk factors, and accounting for them leads to significantly more accurate estimation of cardiovascular risk.     

Outcome after coronary artery bypass surgery and percutaneous coronary intervention in patients with atrial fibrillation and oral anticoagulation

Abstract

Aim. This study was planned to compare the clinical characteristics and outcome of patients on warfarin treatment for atrial fibrillation (AF) undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

Methods. This is a retrospective analysis of 121 patients who underwent isolated CABG and 301 patients who underwent PCI.

Results. PCI patients were older (mean age, 72.9 versus 69.8 years) and more often had prior cardiac surgery (15.9% versus 1.7%) and acute coronary syndrome (53.8% versus 21.5%). CABG patients more often had two- and three-vessel disease (95.0% versus 60.2%) and left main stenosis (32.2% versus 7.0%). The 30-day outcome was similar after PCI and CABG. At 3 years, PCI was associated with lower overall survival (72.0% versus 86.4%, P = 0.006), freedom from repeat revascularization (85.3% versus 98.2%, P < 0.001), freedom from myocardial infarction (83.4% versus 93.8%, P = 0.008), and freedom from major cardiovascular events (57.4% versus 78.9%, P < 0.001). Propensity score adjusted analysis showed that PCI was associated with increased risk of all-cause mortality (P = 0.016, RR 2.166, CI 1.155–4.060), myocardial infarction (P = 0.017, RR 3.161, 95% CI 1.227–8.144), repeat revascularization (P = 0.001, RR 13.152, 95% CI 2.799–61.793), and major cardiac and cerebrovascular complications (P = 0.001, RR 2.347, 95% CI 1.408–3.914). There was no difference in terms of stroke and bleeding episodes at any time point.

Conclusion. In clinical practice, PCI is the preferred revascularization strategy in these frail patients. Patients selected for CABG have a relatively low operative risk and better mid-term outcome in spite of warfarin treatment. The poor prognosis after PCI may mainly reflect frequent co-morbidities in this patient group.     

Lowering C-reactive protein with statins after an ischemic stroke avoids mortality and readmissions. A prospective cohort study

Abstract

Aims. A hypothetical benefit of statins after an ischemic stroke could be provided by their pleiotropic effects. Our aim is to test if statins are able to avoid mortality and readmissions of patients with ischemic stroke, by lowering their levels of not only LDL-cholesterol but also CRP.

Methods. A prospective cohort study was performed. Pre-stroke and post-stroke medications were recorded. Cholesterol and hsCRP levels were measured at admission and 90 days post-stroke. Rankin score and fatality or readmissions were assessed at 90 days and 1 year. We have used robust statistical methods.

Results. Of 359 stroke patients, statins were prescribed before stroke onset in 30.6% (110/359) and were begun during hospitalization in an additional 32.3% (116/359). In logistic regression analysis adjusted, statins therapy was independently associated with improved total mortality (OR 0.30; 95% CI 0.11–0.86; P < 0.02), improved cardiovascular mortality (OR 0.29; 95% CI 0.08–0.98; P < 0.04), and improved total mortality and readmission rates (OR 0.35; 95% CI 0.18–0.7; P < 0.003). In the final model, lowering the levels of hsCRP by 0.4mg/dL, a 30% of mortality or readmissions would be avoided.

Conclusions. Therapy with statins, either previous or early initiation, after an ischemic stroke, could improve the survival and readmission rates by lowering both cholesterol and hsCRP levels.     

Safety and efficacy of protease‐activated receptor‐1 antagonists in patients with coronary artery disease: a meta‐analysis of randomized clinical trials

Summary. Background: Thrombin receptor antagonists blocking protease‐activated receptor‐1 (PAR‐1) on platelets represent a new class of oral antiplatelet agents for patients with atherothrombotic disease manifestations. Objectives: We investigated the safety and efficacy of PAR‐1 antagonists in patients with coronary artery disease (CAD). Patients/Methods: Randomized, placebo‐controlled trials of the PAR‐1 antagonists atopaxar or vorapaxar in CAD patients were identified. The primary safety endpoint was the composite of Thrombolysis In Myocardial Infarction (TIMI) clinically significant bleeding. The primary efficacy endpoint was the composite of death, myocardial infarction (MI) or stroke. Results: A total of 41 647 patients from eight trials were included. PAR‐1 antagonists were associated with higher risks of TIMI clinically significant (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.39–1.57, P < 0.001), major (OR 1.46, 95% CI 1.28–1.67, P < 0.001) and minor (OR 1.67, 95% CI 1.40–2.00, P < 0.001) bleeding than placebo in the fixed‐effects model. PAR‐1 antagonists reduced the composite of death, MI or stroke as compared with placebo (OR 0.87, 95% CI 0.81–0.92, P < 0.001), driven by a lower risk of MI (OR 0.85, 95% CI 0.78–0.92, P < 0.001). Conversely, PAR‐1 antagonists and placebo did not differ in terms of risk of death (OR 0.99, 95% CI 0.90–1.09, P = 0.81) or stroke (OR 0.96, 95% CI 0.84–1.10, P = 0.59). Conclusions: PAR‐1 antagonists decrease ischemic events in patients with CAD as compared with placebo, mainly driven by a reduction in MI, at the cost of an increased risk of clinically significant bleeding.     

Association between Tomographic Characteristics of the Temporal Bone and Transtemporal Window Quality on Transcranial Color Doppler Ultrasound in Patients with Stroke or Transient Ischemic Attack

Transcranial color-coded Doppler (TCCD) is an ultrasonographic technique used to obtain and evaluate images of the cerebral parenchyma and to assess blood flow velocities of the intracranial vessels. One of the major limitations of TCCD is the failure to insonate through the transtemporal window, which occurs in about 5%–44% of patients. Temporal bone thickness has been strongly associated with transtemporal window failure (TWF). The aims of the study were to evaluate the association between TWF on TCCD and radiologic findings on computed tomography of the skull along with the demographic characteristics of patients with acute stroke or transient ischemic attack (TIA), and to propose a classification for transcranial window quality (TWQ) on B-mode scan of TCCD. A total of 187 consecutive patients with acute stroke or TIA were included. Among them, 21.9% had TWF and 34.8% had TWQ categorized as insufficient on B-mode scan of TCCD. On logistic regression, age (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.03–1.12, p < 0.001), female sex (OR = 5.99, 95% CI: 2.09–17.16, p = 0.001), pneumatized temporal bone (OR = 7.90, 95% CI: 1.95–32.03, p = 0.004) and temporal bone thickness (OR = 3.04, 95% CI: 1.73–5.35, p < 0.001) were independent predictors of TWF, even after adjusting for confounders. These findings may help to select patients in whom echogenic contrast or even other imaging methods could be used to assess intracranial vessels.     

Nurses' views on the provision of physical healthcare for individuals with comorbid mental illness and chronic disease

The prevalence of chronic diseases (such as diabetes, obesity, cancer, heart disease, and chronic obstructive pulmonary disease) continues to increase among patients with mental illness. This cross-sectional study investigated the factors affecting nurses' views on the provision of physical healthcare to patients with comorbid mental illness and chronic disease. In total, 369 nurses working in mental health were assessed for the physical healthcare attitudes and practices using the Physical Health Attitude Scale for Mental Health Nurses. The results of generalized linear modelling indicated that nurses' involvement in physical healthcare was associated with psychiatric mental health nurse credentials (B = 1.560, 95% CI = 0.292–2.828, P = 0.016) and their confidence in delivering physical healthcare was associated with prior physical healthcare training (B = 0.639, 95% CI = 0.104–1.174, P = 0.019). In addition, the frequency with which the nurses engaged in physical healthcare practices was associated with working in a community unit (B = −7.416, 95% CI = −9.652 to −5.180, P < 0.001), involvement in physical healthcare (B = 0.349, 95% CI = 0.162–0.535, P < 0.001), and confidence in delivering physical healthcare (B = 1.148, 95% CI = 0.776–1.519, P < 0.001). Our findings suggest that interventions aiming to help nurses assess and improve their own physical healthcare practices should consider nurses' background and patients' physical health needs in various settings and focus on cultivating an organizational culture that gives nurses confidence in providing physical healthcare.     

Edaravone for Acute Ischemic Stroke: A Systematic Review and Meta-analysis

PurposeThe management of acute stroke is challenging. The aim of this meta-analysis was to determine the efficacy and tolerability of edaravone, with or without thrombolytic therapy, in the treatment of patients with acute ischemic stroke.MethodsThe PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) and cohort studies. Mean differences (MD), risk ratios (RR), 95% confidence interval (CI), and heterogeneity were calculated.FindingsTotals of nine RCTs and four cohort studies were included, for a total of 2102 patients. In patients with acute ischemic stroke, edaravone monotherapy was associated with significantly improved Barthel Index of functioning in activities for daily living (MD, 23.95; 95% CI, 18.48 to 29.41; P < 0.001) and neurologic deficit, (as measured using the National Institutes of Health Stroke Scale score) (MD = –3.49; 95% CI, –5.76 to 1.22; P = 0.003), on short-term follow-up. However, edaravone was not associated with an improved rate of death or disability (RR = 0.75; 95% CI, 0.45 to 1.23; P = 0.25) on long-term follow-up.When plus to thrombolytic therapy, edaravone was associated with significant improvements in recanalization rate (RR = 1.71; 95% CI, 1.05 to 2.77; P = 0.03) and neurologic deficit (MD = 3.97; 95% CI, 5.14 to 2.79; P < 0.001), without an increase in the prevalence of bleeding events (RR = 1.11; 95% CI, 0.76 to 1.62; P = 0.59). However, edaravone did not have a significant effect on death or disability (RR = 0.85; 95% CI, 0.69 to 1.04; P = 0.12).ImplicationsBased on the findings from the present meta-analysis, edaravone was an effective and well-tolerated neuroprotective agent in these patients with ischemic stroke. With the use of edaravone, activities of daily living and neurologic deficits, along with recanalization rates, were improved on short-term follow-up, but the long-term effects still need confirmation in larger-scale clinical trials.     

ECG markers associated with ischemic stroke at young age – a case-control study

Introduction: Certain electrocardiographic (ECG) abnormalities are associated with ischemic stroke (IS), especially cardioembolic subtype. Besides atrial fibrillation, markers of left ventricular hypertrophy (LVH) or atrial pathology also reflect elevated risk. We studied the association of ECG markers with IS in young adults.

Methods: We performed a case-control study including 567 consecutive IS patients aged 15–49 years (inclusion period: 1994–2007) and one or two age- and sex-matched control subjects enrolled during 1978–1980 (n?=?1033), and investigated also the stroke aetiologic subgroups. We studied ECGs of all participants for markers of atrial abnormality, i.e. P-terminal force (PTF) on lead V1, interatrial blocks (IAB; P-wave duration?≥110?ms), and LVH. Conditional logistic regression analyses were used.

Results: IAB (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.16–2.13) and PTF combined with LVH (HR: 6.83, 95% CI: 1.65–28.31), were independently associated with IS. LVH, abnormal P-wave (HR: 6.87, 95% CI: 1.97–135.29), PTF, IAB, and combinations of these P-wave abnormalities with LVH – were associated with cardioembolic subtype. Abnormal P-wave and IAB were associated with cryptogenic stroke subtype. In unadjusted analysis, LVH was associated with small-vessel disease subtype.

Conclusion: P-wave abnormalities on ECG were associated with cardioembolic but also with a cryptogenic subtype of IS.

• Key messages

• ECG patterns associated with atrial pathology are markers of increased risk of ischemic stroke in young adults.

• The ECG markers reflecting atrial pathology were seen in patients with cardioembolic and cryptogenic subtypes of ischemic stroke.

     

ABO genotype and risk of thrombotic events and hemorrhagic stroke

Summary. Background: The non‐O alleles of the ABO genotype have been associated with an increased risk of thrombosis. Risk associated with the specific A¹, A² or B alleles is not well defined. Objectives: To examine the association of the ABO genotype with myocardial infarction (MI), ischemic stroke, hemorrhagic stroke, and venous thrombosis (VT). Patients and methods: We used data from two ongoing population‐based case–control studies of MI, stroke, and VT. Cases included hypertensive adults and postmenopausal women with incident non‐fatal MI (n = 1063), ischemic stroke (n = 469), and hemorrhagic stroke (n = 91), and postmenopausal women with incident non‐fatal VT (n = 504). Controls were frequency matched to cases on age, sex, hypertension status, and year of identification. ABO genotypes were determined using single‐nucleotide polymorphisms, and subjects were grouped by diplotype according to the presence of O¹, O², A¹¹, A² and B alleles. Logistic regression was used to test the association of diplotypes with risk of each outcome. Results: As compared with the O¹O¹ group, the A¹¹ allele was associated with an increased risk of VT [odds ratio (OR) 1.79; 95% confidence interval (CI) 1.41–2.26] and MI (OR 1.23; 95% CI  1.05–1.44). The B allele was associated with an increased risk of VT (OR 1.82; 95% CI  1.29–2.57) and ischemic stroke (OR 1.59; 95% CI  1.17–2.17). The AB diplotype category was associated with a 2.7‐fold risk of VT (OR 2.70; 95% CI  1.73–4.21). No other associations reached significance. Conclusions: The VT and MI findings are confirmatory, and the ischemic stroke finding with the B allele is a novel finding and needs replication.     

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department

Objective: To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED. Methods: A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross‐sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non‐consecutive participants. Participants were categorized as non‐fallers, frail mechanical or active mechanical fallers. Self‐reported falls in past 6 months and hospital admission were documented. Results: Participant age and sex (median age 74, interquartile range 65–82 years; male 59%, 74/126, 95% CI 50–67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9–21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non‐faller (relative risk [RR]: 1.5, 95% CI 1.0–2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0–10.9, Fisher's Exact test P= 0.02) or a non‐faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0–2.1, P= 0.001). Malnourished participants had an increased risk of self‐reported falls over 6 months (RR: 1.5, 95% CI 1.0–2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well‐nourished (RR: 5.3, 95% CI 1.4–20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78–92%) of participants assessed as malnourished by Subjective Global Assessment. Conclusions: Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.     

Glu298Asp and NOS4ab polymorphisms in diabetic nephropathy

Background and aims. The risk of diabetic nephropathy (DN) increases with increase in intraglomerular pressure, which may partly be regulated by nitric oxide (NO). NO‐production can be affected by polymorphisms in the endothelial NO‐synthase gene (NOS3), hyperglycaemia and smoking. We therefore studied association between DN and two polymorphisms in NOS3, Glu298Asp and NOS4ab, in Caucasian type 1 diabetes (T1D) patients.

Patients and methods. A total of 1510 Finnish and Swedish T1D patients were included in a cross‐sectional case‐control study. Incipient DN was defined as an albumin excretion rate (AER) of 20–200?µg/min (n = 336). Overt DN = AER>200?µg/min or renal replacement therapy (n = 619). All patients with DN were considered as cases. The controls were T1D patients with diabetes duration ?20 years, AER<20?µg/min and without antihypertensive treatment (n = 555). The genetic markers studied were a 27?bp repeat (NOS4ab) and Glu298Asp (rs1799983).

Results. Age at onset of diabetes, male sex, duration of diabetes, HbA1c, blood pressure and smoking were assessed as possible confounders in the logistic regression analysis, which showed that homozygosity for the Glu‐allele of the Glu298Asp‐polymorphism was independently associated with increased risk of DN (OR = 1.46; 95% CI = 1.12–1.91). The variables smoking (OR = 2.13; 95% CI = 1.63–2.78), male sex (OR = 1.61; 95% CI = 1.23–2.10), HbA1c (OR per % increase above upper limit of the normal reference range = 1.02; 95% CI = 1.02–1.03), systolic (OR = 1.05; 95% CI = 1.04–1.06) and diastolic blood pressure (OR = 1.04; 95% CI = 1.02–1.05) also significantly and independently increased the risk of DN when taking age at diabetes onset and diabetes duration into account. The NOS4 a‐allele was not associated with DN.

Conclusions. The Glu/Glu‐genotype of the NOS3 Glu298Asp polymorphism may increase the risk of developing DN independently of other known risk factors.     

Electrocardiographic presentation of global ischemia in acute coronary syndrome predicts poor outcome

Abstract

Background. Global ischemia (GI) electrocardiogram (ECG), wide-spread ST depression with inverted T waves maximally in leads V_4–5, and lead aVR ST elevation (STE), is a marker of an adverse outcome in patients with non-ST elevation acute coronary syndromes (ACS), perhaps because this pattern is indicative of left main stenosis. The prognostic value of this ECG pattern has not been established.

Aims. The distribution of ECG changes and the prognostic value of the GI ECG were studied.

Methods. ECGs of consecutive patients admitted with suspected ACS (n = 1,188) were classified into seven ECG categories: STE, Q waves without STE, left bundle branch block, left ventricular hypertrophy, GI ECG, other ST depression and/or T wave inversion, and other findings.

Results. The GI ECG pattern predicted a high rate (48%) of composite end-points (mortality, re-infarction, unstable angina, resuscitation, or stroke) at 10-month follow-up compared to the other ECG categories (36%) (HR 1.78; CI 95% 1.31–2.41; P < 0.001). In multivariate analysis, the GI ECG pattern was associated with a higher rate of composite end-points (HR 1.40; CI 95% 1.02–1.91; P = 0.035). The multivariate analysis furthermore identified age, creatinine level, and diabetes as independent predictors of prognosis.

Conclusions. The GI ECG pattern predicted an unfavorable outcome, when compared to other ECG patterns in patients with ACS.     

Renal artery stenosis predicts adverse cardiovascular and renal outcome in patients with peripheral artery disease

Background Patients with symptomatic peripheral artery disease (PAD) are considered cardiovascular high‐risk patients. Our aim was to investigate whether incidental renal artery stenosis (RAS) increases the risk for adverse cardiovascular and renal outcomes in these patients. Materials and methods We prospectively enrolled 487 consecutive patients admitted for revascularization of symptomatic PAD and performed a renal overview angiogram categorizing RAS as absent (0–29%), moderate (30–59%) and severe (≥ 60%) respectively. Clinical follow‐up was for median 15 months (IQR 12–22) for the occurrence of major adverse events [MAE: composite of death, myocardial infarction (MI), stroke, percutaneous coronary intervention, coronary bypass surgery, amputation and kidney failure]. Glomerular filtration rates (GFR) were obtained at 12 months to quantify the course of renal function. Results A severe RAS was found in 76 patients (15·6%). Overall MAE occurred in 121 patients (24·8%), the composite endpoint of MI, stroke, amputation and death occurred in 101 patients (20·7%). Patients with a severe RAS had a 1·87‐fold increased adjusted risk for MAE (95% CI 1·12–3·12, P = 0·017), a 2·51‐fold increased adjusted risk for occurrence of the composite endpoint of MI, stroke, amputation and death (95% CI 1·45–4·34, P = 0·001) and a 2·93‐fold increased risk for death (95% CI 1·41–6·08, P = 0·004), compared to those of patients without RAS respectively. We observed a significant association between the decrease of GFR over the 12‐month follow‐up period and the severity of RAS by multivariable analysis (P = 0·044). Conclusion Severe RAS in patients with symptomatic PAD is an independent predictor of major adverse cardiovascular events, adverse renal outcome and mortality.     

Venous thromboembolism and subsequent diagnosis of subarachnoid hemorrhage: a 20‐year cohort study

Summary. Background: Venous thromboembolism is a predictor of subsequent risk of ischemic stroke and intracerebral hemorrhage, but no data are available regarding its association with risk of subarachnoid hemorrhage. Objectives: To examine this issue, we conducted a nationwide cohort study in Denmark. Patients and methods: Between 1977 and 2007, we identified 97 558 patients with a hospital diagnosis of venous thromboembolism and obtained information on risk of subsequent subarachnoid hemorrhage during follow‐up in the Danish Registry of Patients. The incidence of subarachnoid hemorrhage in the venous thromboembolism cohort was compared with that of 453 406 population control cohort members. Results: For patients with pulmonary embolism (PE), there was clearly an increased risk of subarachnoid hemorrhage, both during the first year of follow‐up [relative risk 2.69; 95% confidence interval (CI), 1.32–5.48] and during later follow‐up of 2–20 years (relative risk 1.40; 95% CI, 1.05–1.87). For patients with deep venous thrombosis (DVT) the risk was likewise clearly increased during the first year of follow‐up (relative risk 1.91; 95% CI, 1.13–3.22), but not during later follow‐up (relative risk 1.04; 95% CI, 0.81–1.32). Conclusions: We found evidence that PE is associated with an increased long‐term risk of subarachnoid hemorrhage. The two diseases might share etiologic pathways affecting the vessel wall or share unknown risk factors.     

Arterial stiffness and vascular complications in patients with type 1 diabetes: The Finnish Diabetic Nephropathy (FinnDiane) Study

Abstract

Introduction/aims. While patients with type 1 diabetes (T1D) are known to suffer from early cardiovascular disease (CVD), we examined associations between arterial stiffness and diabetic complications in a large patient group with T1D.

Methods. This study included 807 subjects (622 T1D and 185 healthy volunteers (age 40.6 ± 0.7 versus 41.6 ± 1.2 years; P = NS)). Arterial stiffness was measured by pulse wave analysis from each participant. Furthermore, information on diabetic retinopathy, nephropathy, and CVD was collected. The renal status was verified from at least two out of three urine collections.

Results. Patients with T1D without signs of diabetic nephropathy had stiffer arteries measured as the augmentation index (AIx) than age-matched control subjects (17.3% ± 0.6% versus 10.0% ± 1.2%; P < 0.001). Moreover, AIx (OR 1.08; 95% CI 1.03–1.13; P = 0.002) was associated with diabetic laser-treated retinopathy in patients with normoalbuminuria in a multivariate logistic regression analysis. The same was true for AIx and diabetic nephropathy (1.04 (1.01–1.08); P = 0.004) as well as AIx and CVD (1.06 (1.00–1.12); P = 0.01) in patients with T1D.

Conclusions. Arterial stiffness was associated with microvascular and macrovascular complications in patients with T1D.     

Comparison between idiopathic deep vein thrombosis of the upper and lower extremity regarding risk factors and recurrence

Summary. Background: The pathogenesis and natural course of idiopathic upper extremity deep vein thrombosis (UEDVT) are unclear. Objective: To compare patients with UEDVT and with idiopathic lower extremity deep vein thrombosis (LEDVT) regarding risk factors and recurrence. Methods: We followed 50 patients with first idiopathic UEDVT and 841 patients with first idiopathic LEDVT for an average of 59 and 46 months, respectively. We excluded patients with natural inhibitor deficiency, lupus anticoagulant, cancer, pregnancy, isolated pulmonary embolism (PE), or long‐term antithrombotic treatment. The endpoint was recurrent venous thromboembolism (VTE). Results: In comparison to LEDVT patients, UEDVT patients were younger (38 ± 13 years vs. 49 ± 16 years, P < 0.001), slimmer (body mass index: 24 ± 4 vs. 27 ± 5, P < 0.001), less frequently had a family history of VTE (18% vs. 31%, P = 0.06) or concomitant PE (8% vs. 31%, P =0.001), were less frequently carriers of factor V Leiden (12% vs. 30%, P = 0.009), and had lower thrombin generation marker levels (D‐dimer, 283 ± 361 ng mL^?1 vs. 456 ± 446 ng mL^?1, P < 0.001; peak thrombin, 298 ± 101 nm vs. 363 ± 111 nm , P = 0.001). Recurrence occurred in two of 50 patients with UEDVT (4%) and in 129 of 841 patients with LEDVT (15%). After 5 years, the likelihood of recurrence was 2% [95% confidence interval (CI) 0–6] among UEDVT patients and 19% (95% CI  16–22; P = 0.02) among LEDVT patients. As compared to LEDVT patients, the adjusted risk of recurrence was 0.26 (95% CI  0.06–1.05; P = 0.059) in UEDVT patients. Conclusion: The pathogenesis and natural course of the disease differ between patients with idiopathic UEDVT and LEDVT.     

Mortality due to pulmonary embolism,myocardial infarction,and stroke among incident dialysis patients

See also Zoccali C, Mallamaci F. Pulmonary embolism in chronic kidney disease: a lethal, overlooked and research orphan disease. This issue, pp 2481–3. Summary. Background: It is has been suggested that dialysis patients have lower mortality rates for pulmonary embolism than the general population, because of platelet dysfunction and bleeding tendency. However, there is limited information whether dialysis is indeed associated with a decreased mortality risk from pulmonary embolism. Objective: The aim of our study was to evaluate whether mortality rate ratios for pulmonary embolism were lower than for myocardial infarction and stroke in dialysis patients compared with the general population. Methods: Cardiovascular causes of death for 130 439 incident dialysis patients registered in the ERA‐EDTA Registry were compared with the cardiovascular causes of death for the European general population. Results: The age‐ and sex‐standardized mortality rate (SMR) from pulmonary embolism was 12.2 (95% CI 10.2–14.6) times higher in dialysis patients than in the general population. The SMRs in dialysis patients compared with the general population were 11.0 (95% CI 10.6–11.4) for myocardial infarction, 8.4 (95% CI 8.0–8.8) for stroke, and 8.3 (95% CI 8.0–8.5) for other cardiovascular diseases. In dialysis patients, primary kidney disease due to diabetes was associated with an increased mortality risk due to pulmonary embolism (HR 1.9; 95% CI 1.0–3.8), myocardial infarction (HR 4.1; 95% CI 3.4–4.9), stroke (HR 3.5; 95% CI 2.8–4.4), and other cardiovascular causes of death (HR 3.4; 95% CI 2.9–3.9) compared with patients with polycystic kidney disease. Conclusions: Dialysis patients were found to have an unexpected highly increased mortality rate for pulmonary embolism and increased mortality rates for myocardial infarction and stroke.