Elevated d‐Dimer Level is a Risk Factor for Coronary Artery Lesions Accompanying Intravenous Immunoglobulin‐Unresponsive Kawasaki Disease

Although there are many reports on the resistance of Kawasaki disease (KD) to initial intravenous immunoglobulin (IVIg) therapy, risk factors for coronary artery lesions in such cases remain to be established. The objective of this study was to explore when additional therapies should be administered and to identify factors helpful for selecting a therapeutic option. Based on their written clinical records, we performed a retrospective review of KD patients who did not respond to initial IVIg therapy and who therefore then underwent plasma exchange (PE) therapy. This was a case‐control study to compare the presence or absence of acute coronary lesions in patients treated by PE for IVIg‐unresponsive KD at Yokohama City University Hospital or at Yokohama City University Medical Center. Fifteen of 44 patients had acute coronary artery lesions (CAL) correlating with high levels of white blood cells (WBC) (P = 0.045), d ‐dimer (P = 0.008), and fibrin/fibrinogen degradation products (P = 0.009) and lower levels of fibrinogen (P = 0.013) prior to PE therapy. There was a strong correlation between pre‐PE levels of albumin and d ‐dimer (Pearson's correlation coefficient of 0.610). Multivariate analyses revealed that the odds ratio for CAL when d ‐dimer was ≥ 4.5 μg/mL was 25.06 (95% CI, 2.56–244.91, P = 0.006). d ‐dimer elevation and albumin decline in IVIg‐unresponsive KD patients could be risk factors for acute CAL, suggesting the possibility that angitis has spread throughout the arterial system, as far as the coronary artery.     

缺血性中风患者测定血浆D—二聚体水平的意义

目的：探讨血浆D－二聚体水平与不同时相、不同面积缺血性中风患的关系。方法：采用胶乳凝聚法按不同年龄组分别测定92例正常人和118例缺血性中风患急性期和恢复期血浆中的D－二聚体含量。结果：缺血性中风患急性期及恢复期血浆D－二聚体的含量均较正常对照组明显升高（P＜0．001）,以急性期最高,恢复期D－二聚体含量已出现下降,与急性期相比有显性意义（P＜0．05）,但仍明显高于正常对照组（P＜0．05）。并且与梗死面积呈正相关;正常人D－二聚体含量随年龄的增高有增长的趋势,低年龄组与高年龄组有显性差异（P＜0．01）。结论：缺血性中风患急性期确实存在高凝状态,血浆D－二聚体水平不仅可作为观察缺血性中风病情轻重的指标,而且也是判断预后、观察治疗效果的监测指标之一。     

肿瘤患者的缺血性卒中

缺血性卒中是恶性肿瘤的重要并发症之一。肿瘤患者缺血性卒中的病因和发病机制非常复杂,既包括高血压、糖尿病、高脂血症等传统血管危险因素,又包括与肿瘤病理生理学状态相关的危险因素,例如高凝状态、肿瘤栓子、血栓性心内膜炎等。此外,与肿瘤相关的各种治疗方法,例如放疗、化疗和内分泌治疗,也会增高缺血性卒中的风险。由于病因和发病机制的复杂性,肿瘤患者缺血性卒中的治疗方法也与常规有所不同,因此,明确病因并选取针对性的治疗方法对于肿瘤患者缺血性卒中的防治极为关键。随着肿瘤患者生存率的提高,肿瘤患者缺血性卒中也越来越受到重视。文章对肿瘤患者缺血性卒中的病因、发病机制和治疗的研究进展进行了综述。     

Pre admission treatment with Beta‐blockers in hypertensive patients with acute stroke and 3‐month outcome—Data from a national stroke registry

The impact of beta‐blockers (BB) treatment on stroke outcome is unclear. We used data from a prospective national stroke registry to assess the associations between use of BB and poor outcome 3 months after stroke. Using the National Acute Stroke Israeli (NASIS) registry, we identified 1126 patients with ischemic stroke and intracerebral hemorrhage with pre‐stroke hypertension treatment, who were followed for 3‐months. Functional outcome and mortality at 3‐month were compared by use of BB, adjusting for demographics and clinical factors. Pre‐stroke use of BB was reported by 615 (54.6%) patients. Users of BB showed higher rates of atrial fibrillation, heart disease, statin use, cancer, and severe stroke. Adjusted odds‐ratios (ORs, 95% CI) for BB users compared with non‐users 3 months after stroke were 0.86 (0.49‐1.52) for mortality and 1.07 (0.76‐1.50) for Barthel Index ≤60. In conclusion, treatment with BB is not associated with 3‐month poor outcome in hypertensive patients.     

Effect of antihypertensive medications on thrombolysis therapy and outcomes in acute ischemic stroke patients

There are concerns that specific risk factors may alter the benefits of thrombolysis in stroke patients with controlled contraindications including hypertension. The objective of this study was to evaluate the association between clinical risk factors and outcomes in ischemic stroke patients that received thrombolysis therapy pretreated with antihypertensive medications. Using data obtained from a stroke registry, a non‐randomized retrospective data analysis was conducted on patients with the primary diagnosis of acute ischemic stroke with hypertension pretreated with antihypertensive medications. The association between clinical risk factors and functional ambulatory outcome was determined using logistic regression while odd ratios (OR) were used to predict the odds of achieving improved ambulatory outcome in thrombolysis treatment status. Improved or poor functional ambulatory outcome was considered as the end point in our analysis. A total of 4665 acute ischemic stroke patients were identified, of whom 1446 (31.0%) were eligible for thrombolysis, while 3219 were not, and 595 received rtPA, of whom 288 were on antihypertensive medications, while 233 were not. In the rtPA group with antihypertensive (anti‐HTN) medication, only NIHSS score (OR = 1.094, 95% CI, 1.094‐1.000, P = 0.005) was associated with improved functional outcome while patients with congestive heart failure (OR = 0.385, 95% CI, 0.385‐0.159, P = 0.035) and patients with a history of previous TIA (OR = 0.302, 95% CI, 0.302‐0.113, P = 0.017) were more likely to be associated with poor functional outcomes. Congestive heart failure and TIA are independent predictors of functional outcomes in stroke patients pretreated with antihypertensive medications prior to thrombolysis therapy.     

Blood pressures immediately following ischemic strokes are associated with cerebral perfusion and neurologic function

The optimal range of blood pressure levels in the early phase of ischemic stroke with hypertension is still controversial. Based on our stroke registry database, we explored the relationship between blood pressure levels and cerebral perfusion in the early phase of ischemic stroke with hypertension and neurofunctional recovery at 3 months after stroke. Total 732 stroke patients with hypertension were finally analyzed. Patients were divided into quintiles according to systolic blood pressure (SBP) and diastolic blood pressure (DBP) to perform multivariable logistic regression to analyze their relation with neurofunctional recovery, respectively. The cerebral perfusion levels displayed a reverse “U” shape curve with the change of blood pressure levels. Sufficient estimated cerebral blood flow (ECBF) in the early phase of ischemic stroke was associated with good neurofunctional recovery at 3 months after stroke. The best neurofunctional recovery was observed in the middle quintiles with SBP at 161 to 177 mm Hg and DBP at 103 to 114 mm Hg, respectively. So maintaining appropriate blood pressure levels in the early phase of ischemic stroke might be beneficial to cerebral perfusion and neurofunctional recovery.     

A panel of biomarkers including caspase-3 and D-dimer may differentiate acute stroke from stroke-mimicking conditions in the emergency department

Abstract. Montaner J, Mendioroz M, Ribó M, Delgado P, Quintana M, Penalba A, Chacón P, Molina C, Fernández‐Cadenas I, Rosell A, Alvarez‐Sabín J (Universitat Autònoma de Barcelona, Vall d’Hebron Hospital, Barcelona, Spain). A panel of biomarkers including caspase‐3 and d ‐dimer may differentiate acute stroke from stroke‐mimicking conditions in the emergency department. J Intern Med 2011; 270 : 166–174. Background and aims. At present, a rapid and widely available diagnostic test for stroke remains elusive. The aim of this study was to examine the predictive value of a panel of blood‐borne biochemical markers for stroke diagnosis. Design. Consecutive patients with strokes or stroke‐mimicking conditions (mimics) were evaluated within 24 h from symptom onset (915 strokes and 90 mimics). Blood samples were analysed by enzyme‐linked immunosorbent assay for C‐reactive protein, d ‐dimer, soluble receptor for advanced glycation end products (sRAGE), metalloproteinase 9 (MMP‐9), S100B, brain natriuretic peptide, caspase‐3, neurotrophin‐3, chimerin and secretagogin. Results. The main independent predictors of stroke versus mimics were caspase‐3 >1.96 ng mL⁻¹ [odds ratio (OR) = 3.32; 95% confidence interval (CI) 1.88–5.88, P < 0.0001], d ‐dimer >0.27 μg mL⁻¹ (OR = 2.97; 95% CI 1.72–5.16, P = 0.0001), sRAGE >0.91 ng mL⁻¹ (OR = 2.19; 95% CI 1.26–3.83, P = 0.006), chimerin <1.11 ng mL⁻¹ (OR = 0.4; 95% CI 0.19–0.81, P = 0.011), secretagogin <0.24 ng mL⁻¹ (OR = 0.51; 95% CI 0.27–0.97, P = 0.041) and MMP‐9 > 199 ng mL⁻¹ (OR = 1.66; 95% CI 1.01–2.73, P = 0.046). The model’s predictive probability of stroke when the six biomarkers are above/below these cut‐off levels was 99.01%. The best combination of biomarkers in the model was caspase‐3 and d ‐dimer. Moreover, a model developed for samples obtained within the first 3 h showed high sensitivity (Se) and specificity (Sp) (threshold at 25th percentile: Se 0.87, Sp 0.55; threshold at 75th percentile: Se 0.28, Sp 0.99). Conclusions. A combination of biomarkers including caspase‐3 and d ‐dimer appears to be the most promising to achieve a rapid biochemical diagnosis of stroke. If replicated, this approach could be used as a tool for urgent referral of stroke patients to hospitals in which acute treatments are available.     

缺血性卒中二级预防的药物依从性调查

目的评估缺血性卒中患者抗血栓药物和危险因素用药的依从性、停药和药物变更原因及影响因素。方法通过电话随访获得卒中患者出院后1年时用药等方面的情况。结果2002年10月至2003年4月北京天坛医院神经内科缺血性卒中患者412例,其中374例患者进入调查,其中完成电话随访者296例(79.1%)。患者抗血栓药物的依从性为35.1%;伴有高血压、糖尿病和高血脂患者1年后仍接受治疗者的比例分别为77.9%、80.2%和48.4%。医保或公费(OR2.117,95%CI1.174～3.821)可促进患者对药物的依从,非阿司匹林抗血栓药物(OR0.352,95%CI0.153～0.812)和较低的日常生活能力指数(62.5±13.3)(MannWhitneyU检验,P=0.000)可明显降低卒中患者的药物依从性。结论卒中二级预防中药物依从性差主要表现为停药和剂量减小。支付方式、收入水平、抗血栓药物的种类以及患者的个人生活能力等可影响卒中患者的药物依从性。     

Plasma levels of soluble glycoprotein VI (sGPVI) are associated with ischemic stroke

Platelet collagen receptor glycoprotein VI (pGPVI) is elevated in patients with acute coronary syndrome (ACS) and ischemic stroke. Recently, we developed a novel bead-based sandwich immunoassay to determine soluble GPVI (sGPVI), which has been validated in ACS patients. This study aimed to evaluate the plasma levels of sGPVI and pGPVI expression in patients with suspected stroke. We consecutively evaluated 176 patients, who were admitted to the stroke unit. Surface expression of pGPVI was determined by flow cytometry, sGPVI concentrations were determined using our sandwich immunoassay. Unlike patients with TIA, patients with stroke showed significantly decreased plasma levels of sGPVI compared to patients with non-ischemic (NI) events (TIA: mean [µg/L]?±?standard deviation): 6.1?±?2.1 vs. NI: 8?±?4; p?=?0.192; stroke: 5.9?±?2.3 vs. NI; p?=?0.013), whereas for pGPVI, patients with TIA and ischemic stroke revealed a significantly increased platelet surface expression compared to NI patients (TIA: mean fluorescence intensity [MFI]?±?standard deviation): 20.9?±?5.4 vs. NI: 17.6?±?5.2; p?=?0.021; stroke: 20.3?±?6.2 vs. NI; p?=?0.016). Using logistic regression analysis, both sGPVI (p?=?0.002) and pGPVI (p?=?0.012) are independently associated with ischemic stroke compared to other laboratory markers. To predict the individual risk for ischemic stroke using the plasma levels of sGPVI, receiver operating characteristic (ROC) analysis determined an optimal cutoff value of sGPVI at 6.5?µg/l, thus, patients with decreased plasma levels (<6.5?µg/l) have a 1.5-fold adjusted odds ratio (95%confidence interval, 1.4–2.7). Lower plasma levels of sGPVI are associated with the slightly elevated risk of stroke and may be a promising novel biomarker.     

缺血性卒中后吞咽功能障碍相关危险因素的分析

目的探讨缺血性卒中患者发生吞咽功能障碍的危险因素。方法连续纳入2009年3月—2011年12月,阜新市第二人民医院神经内科的缺血性卒中患者496例,对患者人口统计学、个人史等临床资料进行回顾性分析,分析缺血性卒中患者吞咽功能障碍的发生率及其危险因素。结果①在496例患者中,发生吞咽功能障碍的有103例,总发生率为20.8%。②吞咽功能障碍的发生率随年龄的升高而上升,年龄〉60岁各组与〈50岁组相对危险度的比较,均成倍增加,均P〈0.05。以小脑梗死为对照,脑干梗死发生吞咽功能障碍的危险度校正后是小脑梗死的3.67倍（95%CI：1.50～8.20）,P〈0.05。③吞咽功能障碍组高血压、糖尿病、不同病灶部位（右侧大脑半球、多发性梗死、脑干梗死）的发病例数均高于无吞咽障碍组,均P〈0.05。校正危险度后结果显示,有糖尿病的缺血性卒中患者发生吞咽功能障碍的危险度是无糖尿病病史的2.55倍（95%CI：0.74～5.99,P〈0.01）,有多发性梗死的患者发生吞咽困难的危险度是无多发性梗死者的2.88倍（95%CI：1.03～5.90,P〈0.05）。结论急性缺血性卒中患者吞咽功能障碍发生的独立危险因素为高龄、高血压、糖尿病、脑干梗死及多发性梗死。     

踝臂指数与老年缺血性脑卒中的相关性研究

目的观察踝臂指数(ABI)与老年缺血性脑卒中的相关性。方法选择住院的老年缺血性脑卒中患者(脑卒中组)180例及非脑卒中老年患者(非脑卒中组)100例,行ABI测量。收集2组患者相关危险因素和实验室检查资料,进行分析。结果脑卒中组和非脑卒中组患者ABI异常患病率分别为37.2%和9.0%;与非脑卒中组比较,脑卒中组患者ABI明显下降(0.95±0.21vs1.06±0.14,P0.01);脑卒中组患者血脂异常和高血压患病率明显高于非脑卒中组(P0.05,P0.01)。logistic回归分析显示,高血压(OR=1.824,95% CI:1.007～3.305,P0.05)和ABI异常(OR=5.292,95% CI:2.477～11.309,P0.01)与老年缺血性脑卒中明显相关。结论 ABI降低的老年患者缺血性脑卒中的发生增加,临床应重视老年患者ABI的检查。     

Sepsis‐associated liver injury: Incidence,classification and the clinical significance

Aim: Although it is a common complication of sepsis, sepsis‐associated liver injury has not been substantially recognized, because its diagnostic criteria and clinical implications are unclear. We aimed to elucidate the incidence, manifestation, disease type classification and prognosis of sepsis‐associated liver injury. Methods: The subjects were 588 patients admitted to our hospital for sepsis between 2001 and 2010. They were classified into “normal liver function”, “sepsis‐associated liver injury” and “sepsis‐not‐associated liver injury” groups. Sepsis‐associated liver injury was classified as either “cholestatic”, “hepatocellular” or “shock liver.” Each of these three subgroups was further classified into “with jaundice” or “without jaundice”. The primary end‐point was the “poor prognosis ratio”, defined as the proportion of patients whose prognosis was “unchanged”, “worsened” or “died”. Results: Among the 449 subjects except for sepsis‐not‐associated liver injury (n = 139), the incidence of sepsis‐associated liver injury was 34.7% (156/449), including 75 cholestatic (48.1%), 34 hepatocellular (21.8%) and 47 shock liver (30.1%) cases. Jaundice was a complication in 25 (33%), six (17.6%) and four (8.5%) patients in each group, respectively. The poor prognosis ratio was higher in males (37.5%) and in the elderly (47.7%); it was 48.0%, 38.2% and 62.8% in the cholestatic, hepatocellular and shock liver groups, respectively, and higher than the normal liver function (18.4%) group (P < 0.0001). It was also higher in patients with jaundice (68.6%) than in those without (45.5%) (P < 0.0001). Conclusion: Sepsis‐associated liver injury, especially with jaundice, is a significant predictive sign of poor prognosis in patients with sepsis.     

缺血性卒中患者的牛津郡社区卒中项目分型与危险因素的关系

目的探讨缺血性卒中患者牛津郡社区卒中项目（OCSP）的分型及各亚型与卒中危险因素的关系。方法前瞻性连续登记发病到入院〈2周的缺血性卒中患者932例。根据OCSP分型标准,将其分为完全前循环梗死（TACI）、部分前循环梗死（PACI）、腔隙性梗死（LACI）及后循环梗死（POCI）4组。记录患者的性别、年龄、民族以及高血压、糖尿病、高脂血症、吸烟、饮酒史情况。分析不同危险因素对各卒中亚型发生风险的影响。结果@932例中,LACI组为463例（49．7％）、PACI组为326例（35．0％）、POCI组为78例（8．4％）、TACI组为65例（7．0％）。②年龄、高血压、糖尿病、高脂血症、脑出血、吸烟史在各亚型组间的差异无统计学意义。POCI组中,男性比例最高（75．6％）;TACI组中,回族（21．5％）、缺血性卒中（36．9％）、心房颤动（20．0％）及短暂性脑缺血发作（TIA）患者（21．5％）的比例最高（21．5％）;LACI组中,饮酒者比例最高（50．3％）。③糖尿病、高血压、高脂血症、吸烟、饮酒、缺血性卒中、TIA、脑出血、心房颤动史对POCI发生的相对危险性差异均无统计学意义;糖尿病、高血压、高脂血症、吸烟史对各型卒中发生的相对危险性差异也均无统计学意义。饮酒史和TIA史增加了LACI的风险（OR=1．488,95％CI：1．148～1．928;OR=1．686,95％C1：1．155—2．462）;缺血性卒中史增加了PACI和TACI的风险（OR=1．466,95％CI：1．058～2．032;OR=2．472,95％CI：1．453—4．205）;脑出血史和心房颤动增加了TACI（OR=2．570,95％CI：1．036—6．379）;OR：4．266,95％CI：2．174—8．368）的风险。结论OCSP各亚型中,LACI亚型的发生率最高;不同的危险因素可能增加OCSP不同亚型的发生风险。     

左心房增大与缺血性卒中

左心房增大是缺血性卒中及其他心血管不良事件的独立危险因素,可影响卒中严重程度并增高复发风险.左心房增大与缺血性卒中之间的相关机制目前仍未明确,可能与心房血栓形成或其共患病相关,例如心房颤动、高血压等.对于存在左心房增大的卒中患者如何实施一级和二级预防仍需要进一步临床试验来确定.     

Association of severe hypertension with pneumonia in elderly patients with acute ischemic stroke

Pneumonia is one of the most frequent complications in elderly patients with acute ischemic stroke. Although severe hypertension is often observed in the early phase of acute stroke, there are few studies of acute hypertension as a factor influencing the incidence of stroke-associated pneumonia (SAP) in elderly subjects with acute ischemic stroke. To assess the association of acute phase blood-pressure elevation with the incidence of SAP, we compared 10 elderly patients with acute ischemic stroke complicated with severe hypertension (≥ 200/120 mm Hg) with 43 patients with moderate hypertension (160-199/100-119 mm Hg), as well as with 65 control normotensive or mildly hypertensive (<160/100 mm Hg) controls on admission. Data were collected on known risk factors, type of ischemic stroke and underlying chronic conditions. The significance of differences in risk factors was analyzed using univariate and multivariate comparisons of 38 SAP cases and others, 8 SAP death cases and others, and 28 patients with poor outcome associated with in-hospital death or artificial feeding at discharge and others. After adjustment for potential confounding factors, the relative risk estimates for SAP, SAP death and poor outcome were 2.83 (95% confidence interval 1.14-7.05), 5.20 (1.01-26.8) and 6.84 (1.32-35.4), respectively, for severe hypertension relative to normotensive or mildly hypertensive controls. We conclude that severe hypertension on admission is an independent predictive factor for SAP in elderly patients with acute ischemic stroke.     

Elevated serum fibrin-monomer levels are associated with high long-term cerebrovascular event rates in acute ischemic stroke patients.

BACKGROUND: Serum fibrin-monomer (FM) is a precursor of stable fibrin, and is a sensitive marker of a systemic hypercoagulable state. It has been reported that, in patients with acute ischemic stroke, higher levels of serum FM reflect intracardiac thrombus formation. METHODS AND RESULTS: Serum coagulation and fibrinolytic activity were measured in 113 patients with acute ischemic stroke within 7 (6+/-1) days after onset. The patients were followed for a mean of 354 (range 36-585) days. The primary endpoints were ischemic stroke recurrence with/without death. FM was markedly higher in the 19 cases with stroke recurrence (49.6+/-53.6 microg/ml) than in the 94 patients without stroke recurrence (14.6+/-30.5 microg/ml; p=0.008). The cerebrovascular event rates were markedly higher in the 12 cases with FM > or =16.5 microg/ml (37.5%) than in the 7 cases with FM <16.5 microg/ml (8.6%; p<0.001). Cox proportional hazards multivariate analysis showed that the FM level was an independent predictor of ischemic stroke recurrence with/without death (hazard ratio, 1.516 per + 1 standard deviation increase; 95% confidence interval, 1.042-2.180; p=0.036). CONCLUSIONS: Elevated serum FM levels in hospitalized ischemic stroke patients may be associated with a persistent systemic hypercoagulable state and high long-term rates of cerebrovascular events.     

Current and future recanalization strategies for acute ischemic stroke

Abstract. Alexandrov AV (University of Alabama Hospital, Birmingham, AL, USA). Current and future recanalization strategies for acute ischemic stroke (Review). J Intern Med 2010; 267: 209–219. In a quest for stroke treatment, reperfusion proved to be the first key to the puzzle. Systemic tissue plasminogen activator (tPA), the first and currently the only approved treatment, is also the fastest way to initiate thrombolyis for acute ischemic stroke. tPA works by induction of mostly partial recanalization since stroke patients often have large thrombus burden. Thus, early augmentation of fibrinolysis and multi‐modal approach to improve recanalization are desirable. This review focuses on the following strategies available to clinicians now or being tested in clinical trials: (a) faster initiation of tPA infusion; (b) sonothrombolysis; (c) intra‐arterial revascularization, bridging intravenous and intra‐arterial thrombolysis, mechanical thrombectomy and aspiration; and (d) novel experimental approaches. Despite these technological advances, no single strategy was yet proven to be a ‘silver bullet’ solution to reverse acute ischemic stroke. Better outcomes are expected with faster treatment leading to early, at times just partial flow improvement rather than achieving complete recanalization with lengthy procedures. Arterial re‐occlusion can occur with any of these approaches, and it remains a challenge since it leads to poor outcomes and no clinical trial data are available yet to determine safe strategies to prevent or reverse re‐occlusion.     

A case control study between diabetic and non-diabetic subjects with ischemic stroke.

AIM: The clinical and prognostic profile of diabetic stroke patients is still an unclarified topic. The aim of the present study is to compare clinical features and risk factor profile in diabetics and in non-diabetics affected by acute ischemic stroke. METHODS: We have included 98 diabetics and 102 matched non-diabetic subjects affected by acute ischemic stroke and matched by age (+/-3 years) and gender. We determined the Scandinavian Stroke Scale (SSS) on admission and the Rankin disability scale on discharge and after a 6 months follow-up. Ischemic stroke has been classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. We anamnestically evaluated the presence of hypertension, hypercholesterolemia, any records of transient ischemic attack, and stroke. Using conditional logistic regression analysis, we calculated adjusted odds ratio (OR) and 95% confidence interval (CI). RESULTS: Diabetes was associated with lacunar ischemic stroke subtype (OR 3.89, 95% CI 2.23-6.8), with a record of hypertension (OR 2.53, 95% CI 1.48-4.32), and with a better SSS score at admission (OR 0.58, 95% CI 0.36-0.96). The association of diabetes with lacunar stroke remained significant also after adjustment for hypertension (adjusted OR 3.37, 95% CI 1.9-5.99) or for large artery atherosclerotic and cardioembolic stroke subtypes (adjusted OR 2.69, 95% CI 1.08-6.69). CONCLUSIONS: Our study shows some significant differences in acute ischemic stroke among diabetics in comparison with non-diabetics (higher frequency of hypertension, higher prevalence of lacunar stroke subtype, lower neurological deficit at admission in diabetics).     

Post‐stroke hypertension control and receipt of health care services among veterans

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post‐stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One‐year post‐discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1‐year post‐discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post‐discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post‐discharge. Provider follow‐ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non‐adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post‐stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non‐adherence were common. Future intervention studies seeking to improve post‐stroke hypertension management should address these observed gaps in care.     

非瓣膜病性心房颤动伴缺血性卒中的复发分析

目的探讨非瓣膜病性心房颤动（房颤）伴缺血性卒中患者的复发及其影响因素。方法回顾性分析1992—2002年住院非瓣膜病性房颤伴缺血性卒中患者386例,随访收集有关临床资料,进行复发分析并研究其复发的相关因素。结果非瓣膜病性房颤伴缺血性卒中患者的10年累计复发率为34％,Cox回归单因素分析发现,高血压、糖尿病、短暂性脑缺血发作（TIA）、高脂血症、附壁血栓是非瓣膜病性房颤伴缺血性卒中患者复发的危险因素,Cox回归多因素分析发现高血压病,TIA发作史与附壁血栓为非瓣膜病性房颤合并缺血性卒中复发的独立危险因素;而阿司匹林与华法林治疗对非瓣膜病性房颤合并缺血性卒中复发有保护作用。结论高血压病、TIA发作史与附壁血栓为非瓣膜病性房颤合并缺血性卒中复发的独立危险因素,阿司匹林与华法林治疗对非瓣膜病性房颤合并缺血性卒中复发有保护作用。