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Tag: Heart

  • Stroke survivors exposed to sexual assault face greater recovery challenges

    Stroke survivors exposed to sexual assault face greater recovery challenges

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    Stressors and traumatic events experienced over the course of a lifetime may negatively impact subsequent stroke recovery; specifically, stroke survivors exposed to sexual assault at any point in their life had poorer physical functioning and cognitive outcomes one year after a stroke, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    It is important to know what has happened to a patient in their life when taking care of them post-stroke. Screening for lifetime stress and trauma is important when caring for a patient who has had a stroke because those experiences often have far-reaching impact and may predict how well a person does over time.”


    E. Alison Holman, Ph.D., lead study author, professor of nursing and psychological science at the University of California, Irvine

    Researchers examined data from the STRONG (Stroke, sTress, RehabilitatiON, and Genetics) study to investigate specific types of stressors that may contribute to adverse physical function and cognitive outcomes one year after stroke. In the STRONG study, stroke survivors were assessed four times during the year. Assessments included the Lifetime Stress and Trauma Exposure survey, completed approximately 90 days after the stroke. Participants reported their lifetime exposure to 31 different types of stressful and/or traumatic events, including witnessing a loved one being injured or killed; sexual assault; divorce; emotional and physical abuse in childhood; and poverty. Additionally, one year after the stroke, participants were assessed for physical function and cognitive abilities. The researchers evaluated the relationships among lifetime stress and trauma exposure and functional and cognitive outcomes among 763 stroke survivors, average age of 63 years.

    The analysis found:

    • Sexual assault was the traumatic event most strongly associated with a moderate decrease in the ability to perform activities of daily living and lower scores on the modified Rankin Scale (describes a person’s ability to function) and Telephone Montreal Cognitive Assessment scores one year after stroke, after controlling for age, gender, race and National Institutes of Health stroke scale score (a measure of stroke severity) three months after a stroke.

    • Other adverse experiences – witnessing a family member be injured or killed; going through a divorce; and/or suffering childhood physical abuse – were also independently associated with a moderate decrease in ability to perform daily living activities one year after stroke.

    • These associations remained even when early post-stroke acute stress levels were accounted for in the analysis.

    • In contrast, taking care of a seriously ill loved one was associated with better scores on the Telephone Montreal Cognitive Assessment. Holman noted that people taking care of others are more actively engaged in everyday life, which may keep the mind sharper. 

    • Women were significantly more likely to report being sexually assaulted and having a seriously ill loved one.

    Holman emphasized that health care professionals should be aware of the potentially lasting physical health impact of sexual assault and other traumatic events that occur over the course of a person’s life. Understanding that these prior life experiences can shape how patients respond to a subsequent stroke may encourage more compassionate communication.

    “Bad things happen to people, so the goal is to intervene in the immediate aftermath of the stroke to prevent its worst effects. We should be able to use this information to allocate resources in a targeted way to provide better support for people during post-stroke recovery,” she said. “Health care professionals can use psychological first aid strategies to support the patients’ basic needs, help them cope and refer them to resources such as a support group or community agency. Sometimes just acknowledging the experience is itself freeing.”

    “This study raises our awareness of how important it is to manage stressors and to increase our physical and mental resilience,” said Randi Foraker, Ph.D., M.A., FAHA, vice chair of the American Heart Association’s Epidemiology & Cardiovascular Stroke Nursing Prevention Science Committee, and professor of medicine, Institute for Informatics, Data Science and Biostatistics and director, Center for Population Health Informatics at Washington University in St. Louis, School of Medicine, Missouri. “Some of the ways we can bolster our resilience and our wellness is to engage in mindful meditation, social engagement and physical activity. As clinicians, researchers and caregivers, we need to make sure we are giving stroke survivors their best chance at living longer, healthier lives.” Dr. Foraker was not involved in the study.

    Study details and background:

    • The study included 763 stroke survivors (average age of 63; 41.3% female; 60.9% white adults).

    • The STRONG study was conducted at 28 stroke centers across the U.S. from 2016-2021.

    • The current study findings build on the STRONG study, led by Holman and her colleague Steven Cramer, M.D., that was previously published in the American Heart Association’s Stroke journal (Sept. 2023), which also suggested that cumulative traumatic stress exposure impairs recovery from stroke.

    The main study limitations were that patients with a severe stroke and those who did not speak English were excluded, so we do not know whether the findings would apply to those patients. Additional research is needed to investigate the potential mechanisms that link these traumatic events to worse outcomes after stroke. Holman suggests it is important to examine both psychological and physiologic processes that may explain the findings.

    Source:

    American Heart Association

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  • Gingko biloba compound injections linked to better stroke outcomes

    Gingko biloba compound injections linked to better stroke outcomes

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    People with ischemic (clot-caused) stroke had better early recovery of cognitive function if treated with intravenous injections of a combination of biologically active components of ginkgo biloba during the first two weeks after the stroke, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    Ginkgo biloba is an herb extracted from the dried leaves and seeds of the gingko tree, one of the oldest living tree species and native to East Asia. It is widely used in traditional Chinese medicine and available as a supplement in the U.S. Compounded therapies of the active ingredients of gingko biloba, delivered by IV, are widely used to treat stroke in China because of its potential antioxidant properties that may protect nerve cells from damage. Ginkgo biloba is not approved by the U.S. Food and Drug Administration for any medicinal use, and there is not enough evidence to support any non-FDA approved use, according to the National Center for Complementary and Integrative Health, a division of the National Institutes of Health.

    In early 2023, researchers from this study published the results of a multicenter trial in China indicating that people with ischemic stroke had better recovery from their overall stroke symptoms if they were treated with daily injections of ginkgo diterpene lactone meglumine (GDLM), a combination of the biologically active components of ginkgo biloba. The current investigation analyzed the cognitive recovery of participants in that study.

    If our positive results are confirmed in other trials, GDLM injections may someday be used to improve cognitive function for patients after ischemic stroke.”


    Anxin Wang, Ph.D., associate professor of clinical epidemiology, Beijing Tiantan Hospital of the Capital Medical University, Beijing

    The researchers analyzed the cognitive recovery of 3,163 stroke survivors (average age of 63 years; 36% women) treated for mild to moderate ischemic stroke at 100 centers in China. Starting within 48 hours of the stroke, about half of the stroke survivors were randomly selected to receive daily, intravenous injections of 25 mg of GDLM for 14 days, while the other half received daily, intravenous placebo injections. Cognitive performance was assessed before treatment, at 14 days and at 90 days using the Montreal Cognitive Assessment scale (MoCA), a 30-point face-to-face screening test of cognitive performance often used with stroke survivors. At baseline -; within 48 hours of the stroke and before beginning treatment, most patients’ cognitive status was moderately impaired, with an average score of 17 out of 30.

    Compared to their initial cognitive screening results:

    • By day 14, stroke survivors who received the ginkgo biloba compound injections had improved cognitive scores in comparison to those who received the placebo (an average of 3.93 points vs. 3.62 points higher, respectively); and

    • By day 90, those who received the ginkgo biloba compound injections had even more improved cognitive scores compared to those who received the placebo (an average of 5.51 points vs. 5.04 points).

    “The proportion of patients who reached a clinically significant level of improvement was 20% higher in the GDLM group, indicating that GDLM injections may improve cognitive function in patients with acute ischemic stroke,” Wang said. “Since the follow-up time in this study was only 90 days, the longer-term effect of GDLM injections requires longer-term research.”

    “GDLM has shown a neuroprotective effect through multiple mechanisms, such as expanding brain blood vessels and improving brain cells tolerance to hypoxia (inadequate oxygen) and increasing cerebral blood flow. GDLM also has neuroprotective antioxidation, anti-inflammation and anti-apoptosis (cell death) properties,” Wang said. “Additionally, laboratory studies have previously indicated that GDLM may promote secretion of chemicals associated with avoiding neurodegenerative diseases, such as Parkinson’s disease and Alzheimer’s disease.”

    In a 2022 American Heart Association Scientific Statement: Complementary and Alternative Medicines in the Management of Heart Failure, it was noted there may be some benefits and potentially serious risks to complementary and alternative medicines, so involving the health care team is critical.

    “While this American Heart Association statement focused on the use of supplements in patients with heart failure, the same approach and caution should be used when treating all cardiovascular diseases including stroke,” said Chair of the scientific statement writing committee Sheryl L. Chow, Pharm.D., FAHA, an associate professor of pharmacy practice and administration at Western University of Health Sciences in Pomona, California, and an associate clinical professor of medicine at the University of California, Irvine. “Stroke patients should not take gingko biloba or other herbs or supplements without discussing it with their doctor and pharmacist. If this new research proves to be effective in future clinical trials it may be a valuable tool for after-stroke care; however, efficacy and safety would need to be demonstrated to meet the same standards as all prescription medications and secure FDA approval.” Dr. Chow was not involved in this study.

    The study was an exploratory analysis conducted within a larger trial, so the results need to be confirmed in an independent trial. These results of adults in China may not be generalizable to people in other countries.

    Source:

    American Heart Association

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  • Nerve stimulation plus physical rehabilitation may boost recovery of arm and hand function

    Nerve stimulation plus physical rehabilitation may boost recovery of arm and hand function

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    Combining brain stimulation with intense physical rehabilitation helped stroke survivors recover movement in their arms and hands and maintain these improvements for one year, according to a study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    The recovery of arm and hand function after a stroke often stalls or even declines, leaving many patients with chronic motor deficits that limit their independence and quality of life. New treatments that can boost the benefits of physical rehabilitation are desperately needed.”


    Teresa J. Kimberley, Ph.D., study’s lead author, professor of rehabilitation science and physical therapy at MGH Institute of Health Professions in Boston

    Vagus nerve stimulation is the first approved neuromodulation device to aid in chronic stroke recovery. It was approved by the U.S. Food and Drug Administration in 2021 to treat moderate to severe upper extremity motor function deficits (physical movement and coordination of arms and hands) associated with chronic stroke.

    “This is the first time that brain stimulation combined with rehabilitation therapy for stroke is available outside of a clinical trial. It could set the stage for even more advancements in recovery from other impairments beyond the arm,” Kimberley said. “This is a watershed moment for rehabilitation science.”

    This study represents one-year outcomes in the VNS-REHAB pivotal trial, which studied people who had a stroke resulting in moderate to severe upper extremity impairment.

    Two groups of participants (108 total people) -; a control group and an experimental group -; completed six weeks of in-clinic, intense rehabilitation paired with active or sham vagus nerve stimulation. All participants were implanted with the nerve stimulation device and then randomized to receive either real nerve stimulation or a sham stimulation that only turned on for a few pulses. The in-clinic therapy was followed by a three-month home exercise program for both groups. The active vagus nerve stimulation group continued the home exercise program for a year. After the six-week period of sham stimulation, the control group crossed over and received six weeks of active vagus nerve stimulation followed by a year of the home exercise program.

    Before and after the stimulation and rehabilitation therapies, motor function was assessed with the Fugl-Meyer Assessment-Upper Extremity, which assesses motor impairment, and the Wolf Motor Function Test, which is a time-based method to evaluate upper extremity motor ability while providing a better understanding of joint-specific and total limb movements.

    The final study results represent outcomes for arm and hand function in 74 stroke survivors after one year of physical rehabilitation treatment. Data was unavailable for the remaining 34 participants mainly due to the COVID-19 pandemic.

    This analysis found:

    • At one-year, upper limb function improved by 5.3 points in the Fugl-Meyer Assessment-Upper Extremity and by 0.51 points in the Wolf Motor Function Test when compared to baseline.

    • Vagus nerve stimulation therapy improved hand and arm function by 2-3 times more than intense rehabilitation alone.

    “The pairing of rehabilitation therapy with vagus nerve stimulation likely helps the brain strengthen new neural pathways – like building a bridge to bypass a damaged area,” Kimberley said.

    “These long-term, pivotal results mirror our long-term results from an earlier pilot study where we found that patients continue to improve or maintain their gains up to three years after starting vagus nerve stimulation therapy paired with rehabilitation,” she said. “As a clinician, it is surprising to see someone with chronic stroke – stroke that in many ways is a progressive disease – continue to improve and not show a decline.”

    Study details and background:

    • The vagus nerve stimulation device in this study included a pacemaker connected to a lead that wraps around the vagus nerve in the neck region. There’s one vagus nerve on each side of the body; each one runs from the lower part of the brain through the neck to the chest and stomach.

    • VNS-REHAB trial participants were between the ages of 22-80 and had a stroke nine months to 10 years prior to study enrollment.

    • Study participants in the experimental group were 64% male and 36% female; 79% white, 17% African American adults, 2% Asian, Indian or other adults, and 1% did not have any race reported. The control group was 65% male and 35% female; 78% white, 16% African American adults, 7% Asian, Indian or other adults, and 1% did not have any race reported.

    • The study took five years to complete: 2017-2019 for enrollment, and the study ended in 2021.

    • The study was triple-blinded, meaning neither the participants, the researchers testing participants nor the health care professionals treating participants knew which intervention group participants were in.

    Study limitations included the small sample size and lack of details about the rehabilitation therapy regimens followed by each participant over the one-year period, which were variable.

    Future studies and an ongoing clinical registry will explore the long-term impact of active vagus nerve stimulation in real-world settings.

    “Often after a stroke, people don’t seek additional treatment, thinking that their current impairments are permanent. This is not true! Paired vagus nerve stimulation opens a new avenue and new hope for these patients. I’m also excited about future research that will investigate vagus nerve stimulation paired with rehabilitation for other conditions, such as gait and speech impairments after stroke,” Kimberley said.

    “These are encouraging findings,” said Joel Stein, M.D., FAHA, chair of the writing group for the American Heart Association’s/American Stroke Association’s 2021 Clinical Performance Measures for Stroke Rehabilitation and the Simon Baruch Professor and chair of the department of rehabilitation and regenerative medicine at Columbia University’s Vagelos College of Physicians and Surgeons; professor and chair of the department of rehabilitation medicine at Weill Cornell Medicine; and physiatrist-in-chief at NewYork-Presbyterian Hospital. “These results demonstrate the durability of the effects of vagus nerve stimulation, an important finding that supports the use of this modality to enhance recovery post-stroke. There is some evidence for lasting improvement with continued use outside of a formal exercise program, which is intriguing, although further research is needed to confirm this finding and clarify who is likely to experience ongoing improvements.” Dr. Stein was not involved in this study.

    Source:

    American Heart Association

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  • Living in poor neighborhoods linked to worse stroke recovery

    Living in poor neighborhoods linked to worse stroke recovery

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    Stroke survivors living in areas with poor economic conditions were twice as likely to have a poor recovery compared to survivors living in areas with better conditions, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    This research was inspired by the people I work with daily. Although stroke patients from differing socioeconomic backgrounds often have similar functional status at discharge, outcomes can vary dramatically a year later. As a clinical research associate, I get to interact with them far beyond the completion of their urgent treatment, which sparked my interest in exploring the long-term outcomes for these patients.”


    Leah Kleinberg, B.A., postgraduate clinical research associate in the Falcone Lab in the department of neurology at Yale School of Medicine in New Haven, Connecticut

    Kleinberg and her colleagues found a significant correlation between functional outcomes after a stroke and the socioeconomic factors noted by census blocks.

    “The magnitude of this impact is what was most surprising. We did not expect a large disparity in outcomes, yet we found patients in the most economically disadvantaged areas were twice as likely to have unfavorable outcomes compared to patients in areas with less unemployment, better housing quality and higher income and education levels,” she said.

    In this study, researchers used data from Yale’s Longitudinal Study of Acute Brain Injury and Area Deprivation Index (ADI) rates for the 2020 U.S. Census blocks to compare outcomes among stroke survivors by socioeconomic disadvantage factors. The ADI evaluates a neighborhood on levels of income, education, employment and housing quality and is specific to each zip code. It was developed by the U.S. Health Resources & Services Administration to inform health care delivery and policy for disadvantaged areas.

    This analysis found:

    • Among 2,164 people with ischemic (clot-caused) stroke, the one-year unadjusted risk of poor outcomes was 35%, 40% and 46% for patients residing in neighborhoods with low, intermediate and high deprivation, respectively.

    • After considering the inability of the ADI to specifically measure each level of deprivation, researchers determined that those living in intermediate and high deprivation areas had 44% and 107% greater risk, respectively, of unfavorable outcomes, compared to patients living in neighborhoods with low deprivation levels.

    • The patients in the poor outcomes category were unable to look after their own affairs without assistance and required some help in daily activities. In the good outcomes category, patients could live independently, though some might have had residual symptoms or disability.

    “We hope this study will help promote awareness of how social determinants of health are as important as clinical variables and health information when trying to identify patients who are particularly high risk for poor long-term outcomes,” she said.

    Study details:

    • The Yale Longitudinal Study follows stroke survivors admitted to the Yale Health System, collecting outcome data at 3 months, 6 months and then yearly after hospital discharge. Zip code data was available for 2,164 patients enrolled in the Yale Longitudinal Study between 2018 and 2021. The average age was 69; 48% were women; 7.5% were Black adults and 7.7% were Hispanic adults.

    • Stroke outcomes were determined by trained assessors using the modified Rankin Scale, which measures disability severity after stroke on a scale of 0-6, from no disability (able to carry out all daily living tasks and duties without assistance) to severe disability (bed-ridden, incontinent, requiring constant nursing care and attention).

    Study limitations are that the Area Deprivation Index relies on geographic blocks and does not evaluate each household separately. Also, due to the observational nature of the study, the findings can only note associations and cannot determine cause and effect.

    When considered separately from other cardiovascular diseases, stroke ranks fifth among all causes of death, behind diseases of the heart, cancer, COVID-19 and unintentional injuries/accidents, according to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update. The Association also recognizes that considering the role of social determinants of health is essential in improving the cardiovascular health of all Americans.

    “Access to quality care, nutritious foods, stable housing or other basic health needs are crucial for people recovering from stroke,” said Elizabeth A. Jackson, M.D., M.P.H., FAHA, immediate past chair of the Association’s Committee on Social Determinants of Health and a professor and director of the Cardiovascular Outcomes and Effectiveness Research Program at the University of Alabama at Birmingham, who was not involved in the research. “Unfortunately, these data are not surprising, rather, they support prior evidence suggesting health disparities are disproportionately experienced in areas where higher degrees of social vulnerability exist.”

    Source:

    American Heart Association

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  • Stroke survivors in gym-rich neighborhoods more likely to stay physically active

    Stroke survivors in gym-rich neighborhoods more likely to stay physically active

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    Stroke survivors were more likely to remain physically active or even exercise more after their stroke if they lived in neighborhoods with easy access to recreational centers and gyms, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    We know that stroke survivors need to be physically active as part of their recovery. Our findings suggest that it’s important to have a conversation with stroke patients about physical activity resources available in their area so they are able to continue their recovery after hospital discharge. If their neighborhood does not offer fitness resources, neurologists should consider discharging the patient to a rehabilitation facility where they can participate in physical activities.”


    Jeffrey Wing, Ph.D., M.P.H., lead study author, assistant professor of epidemiology at The Ohio State University in Columbus, Ohio

    In this study, researchers examined the potential link between available fitness/exercise centers, pools and gyms and physical activity among 333 people living in New York City who had a mild stroke.The data was geocoded, assigned to the U.S. census tracts, and merged with data from the National Neighborhood Data Archive (collects information about the number of physical activity resources at the census tract level). Geocoding is the process of transforming a description of a location -; such as an address or a name of a place -; to a location on the earth’s surface. Researchers then examined the association between the number of fitness and recreational centers, such as pools, gyms and skating rinks per square mile, and the self-reported change in physical activity levels -; more active, about the same or less active -; one year after stroke.

    The analysis found:

    • About 17% of participants reported being more physically active one year after stroke, and 48% reported having about the same level of physical activity as before the stroke.

    • The odds of being more active were 57% higher among participants who lived in areas with more recreational and fitness resources (about 58 fitness resources) compared to people living in neighborhoods with fewer or no fitness resources, after controlling for age, gender, race, ethnicity, education, health insurance and body mass index.

    • Similarly, the odds of reporting the same level of physical activity one year after stroke were 47% higher in participants who lived in areas with more recreational centers and fitness resources compared to those who lived in areas with fewer or no resources available.

    Previous research has shown that even moderate physical activity is beneficial for stroke recovery and can include walking, Wing said. “However, it’s important to recognize the availability or limited availability of exercise resources in a person’s immediate neighborhood and to be able to feel safe while participating in exercise activities.”

    Previous research has found that the characteristics of the built environment of a neighborhood, such as access to healthy food or recreational spaces promoting physical activity, were also linked to lower incidence of stroke, Wing noted.

    “The takeaway from this analysis is that it’s not that people should move to a location where there are more resources to engage in physical activity, but to urge people to find ways to be active in their own neighborhood,” said study co-author Julie Strominger, a Ph.D. student of epidemiology at The Ohio State University. “It’s the action that will lead to better outcomes, so just the action of being physically active is what really matters.”

    “This study is consistent with prior research on the importance of physical activity for optimal health. The new aspect is the focus on stroke survivors,” said American Stroke Association volunteer expert and EPI and Stroke Council member Daniel T. Lackland, Dr.P.H., FAHA, professor of epidemiology and director of the Division of Translational Neurosciences and Population Studies in the department of neurology at the Medical University of South Carolina in Charleston. “It’s important for health care professionals to discuss maintaining physical activity with stroke survivors: find out if they know of a safe place to exercise, and if they do not, have that information readily available.” Lackland was not involved in the study.

    Study details and background:

    • The analysis included 333 adults hospitalized for mild stroke and enrolled in the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study.

    • The DESERVE study was a randomized clinical trial of 546 stroke survivors and conducted in New York City from 2012-2016.

    • Participants were 52% women, with an average age of 65 years; they self-identified as 35% Hispanic adults, 31% Black adults, 28% white adults and 6% as “other” race.

    The main limitations of the study, according to the authors, are that the findings may not be generalizable to non-urban neighborhoods in the U.S. In addition, the data was extracted from a clinical trial that included only stroke survivors who had a mild stroke, therefore, this association may not hold true for survivors of severe stroke. Also, while people in certain neighborhoods reported more physical activity, that does not necessarily mean that they used the fitness and recreational resources in their neighborhood.

    Source:

    American Heart Association

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  • Newer clot-buster may offer a safe, effective way to treat ischemic stroke in mobile stroke units

    Newer clot-buster may offer a safe, effective way to treat ischemic stroke in mobile stroke units

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    Compared with the standard clot-busting medication alteplase, the newer clot-buster tenecteplase may offer a safe, effective and simpler way to treat ischemic (clot-caused) stroke in mobile stroke units, according to real-world experiences detailed in a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    Both tenecteplase and alteplase are clot-busting medications. However, tenecteplase is given in a single injection into the bloodstream, while alteplase requires an hour-long infusion after an initial injection. Alteplase is currently the only FDA-approved clot-buster for treating ischemic stroke. Tenecteplase is FDA-approved for the treatment of clots blocking coronary arteries and is used off-label to treat ischemic stroke.

    One of the most important parts of treating stroke patients is getting them the medication they need as quickly and as safely as possible. We know from a recent, large, randomized study that tenecteplase is superior for stroke treatment when given on an ambulance with imaging capability, however, these findings had not been confirmed outside of a trial. Our study looked at real-world implementation of tenecteplase, and we found that we were able to administer it without delay and provide our stroke patients with safe care as quickly as possible on our mobile stroke unit.”


    J. Tyler Haller, Pharm. D., lead author of the study and clinical pharmacy specialist in neurocritical care at St. Joseph’s Hospital and Medical Center in Phoenix

    The Barrow Neurological Institute in Phoenix has the only mobile stroke treatment unit in Arizona – a specially equipped and staffed mobile emergency room. It is deployed when fire department dispatchers determine that a 911 call indicates a possible stroke patient. The mobile stroke unit is staffed by stroke-certified personnel and includes a CT scanner, portable lab and clot-dissolving medications to help quickly diagnose and treat stroke.

    For this study, the researchers analyzed the electronic medical records of people who received clot-busting medication in the mobile stroke unit between February 2021 and April 2023. The study looked at the medical records of people who received treatment both before and after the mobile stroke unit switched from alteplase to tenecteplase in May 2022. During the study period, 40 participants received alteplase, and 32 participants received tenecteplase. The participants’ median age was 66 years, and their median score on the National Institute of Health Stroke Scale was 9, indicating a moderately severe stroke.

    The study found:

    • There was no significant difference in the time span between a patient’s entry to the mobile stroke unit and the administration of either clot-busting medication.

    • There was no difference in time from: entry to imaging results; dispatch of the unit to the administration of medications; or the clinician’s decision about treatment to the time medications were administered.

    • As an indicator of safety, the researchers compared how often patients developed bleeding in the brain within 24 hours of receiving a clot-busting medication: No patient receiving either medication developed this complication.

    “While there was no significant difference in time to administration across the two medications, health care staff feedback confirmed that the calculation and administration of tenecteplase was easier to administer in comparison to alteplase,” said Tiffany O. Sheehan, Ph.D., R.N., FAHA, senior author of the study and manager, Stroke Center Development, Barrow Neurological Institute at St. Joseph’s Hospital and Medical Center in Phoenix. “Administering a single infusion of tenecteplase is more straightforward and allows health care staff extra time to stabilize patients since they do not have to monitor an hour-long infusion of alteplase. This makes the transfer of patients as they are taken to a hospital less complicated.”

    “Apart from being less expensive, our results confirm tenecteplase is safe and as effective as alteplase. We will continue to collect safety and outcome data on our practice; however, we anticipate that other mobile stroke units across the country will begin to utilize tenecteplase if they are not already,” Haller said.

    “Mobile Stroke Units have been a very exciting development because they reduce the time to treatment, and we know that after a stroke, time is brain. Most cities in the U.S. don’t have this kind of treatment available, though, because of cost. So anything that can be done to reduce costs and other challenges of operating a Mobile Stroke Unit has potential to be impactful. Tenecteplase is increasingly being used because of its ease of use, the lower cost and its comparable safety and effectiveness, compared to tPA,” said Mitchell S. V. Elkind, M.D., M.S., FAHA, chief clinical science officer of the American Heart Association, a past president of the American Heart Association, past chair of the Advisory Committee of the American Stroke Association -; a division of the American Heart Association, and a tenured professor of neurology and epidemiology at Columbia University in New York. Dr. Elkind was not involved in this study.

    The study is limited because it is a retrospective analysis of electronic medical records from a single mobile stroke unit. The researchers studied the time before and after the mobile stroke unit began using tenecteplase and was unable to control for other changes in practice that may have occurred during that time.

    Source:

    American Heart Association

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  • Dementia risk can be the highest in the first year after stroke

    Dementia risk can be the highest in the first year after stroke

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    Having a stroke may significantly increase the risk of developing dementia. The risk of dementia was the highest in the first year after a stroke and remained elevated over a period of twenty years, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    Our findings show that stroke survivors are uniquely susceptible to dementia, and the risk can be up to 3 times higher in the first year after a stroke. While the risk decreases over time, it remains elevated over the long-term.”


    Raed Joundi, M.D., D.Phil., lead study author, assistant professor at McMaster University in Hamilton, Ontario, Canada, and investigator at the Population Health Research Institute, a joint institute of McMaster University and Hamilton Health Sciences

    To evaluate dementia risk after stroke, the researchers used databases at the Institute for Clinical Evaluative Sciences (University of Toronto, Canada), which includes more than 15 million people in the Canadian province of Ontario. They identified 180,940 people who had suffered a recent stroke -; either an ischemic stroke (clot-caused) or intracerebral hemorrhage (bleeding within the brain) -; and matched those stroke survivors to two control groups -; people in the general population (who had not had a heart attack or stroke) and those who had had a heart attack and not a stroke. Researchers evaluated the rate of new cases of dementia starting at 90 days after stroke over an average follow-up of 5.5 years. In addition, they analyzed the risk of developing dementia in the first year after the stroke and over time, up to 20 years.

    The study found:

    • The risk of dementia was highest in the first year after stroke, with a nearly 3-fold increased risk, then decreasing to a 1.5-fold increased risk by the 5-year mark and remaining elevated 20 years later.

    • Dementia occurred in nearly 19% of stroke survivors over an average follow-up of 5.5 years.

    • The risk of dementia was 80% higher in stroke survivors than in the matched group from the general population. The risk of dementia was also nearly 80% higher in stroke survivors than in the matched control group who had experienced a heart attack.

    • The risk of dementia in people who had an intracerebral hemorrhage (bleeding in the brain) was nearly 150% higher than those in the general population.

    “We found that the rate of post-stroke dementia was higher than the rate of recurrent stroke over the same time period,” Joundi said. “Stroke injures the brain including areas critical for cognitive function, which can impact day-to-day functioning. Some people go on to have a recurrent stroke, which increases the risk of dementia even further, and others may experience a progressive cognitive decline similar to a neurodegenerative condition.”

    Each year, about 795,000 people experience a new or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent attacks, according to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update. According to the CDC, of those at least 65 years of age, there is an estimated 7 million adults with dementia in 2014 and projected to be nearly 14 million by 2060.

    “Our study shows there is a large burden of dementia after acute stroke in Canada and identifies it is a common problem that needs to be addressed. Our findings reinforce the importance of monitoring people with stroke for cognitive decline, instituting appropriate treatments to address vascular risk factors and prevent recurrent stroke, and encouraging lifestyle changes, such as smoking cessation and increased physical activity, which have many benefits and may reduce the risk of dementia,” Joundi said. “More research is needed to clarify why some people who have a stroke develop dementia and others do not.”

    A 2023 American Heart Association scientific statement, Cognitive Impairment After Ischemic and Hemorrhagic Stroke suggests post-stroke screenings and comprehensive interdisciplinary care to support stroke survivors with cognitive impairment.

    A limitation of the study is that administrative data, hospital records and medication dispensary data were used for the analysis. Researchers were not able to perform cognitive assessments or neuroimaging (noninvasive images of the brain) on stroke survivors, therefore, there is no way to confirm the dementia diagnosis or type of dementia. However, the dementia definition was previously validated and shown to be accurate when compared to medical charts.

    Study background and details:

    • The study examined data from 2002 to 2022 on a total population of 15 million adults in Ontario, Canada.

    • Data was mined from all hospital admissions, pharmacies prescribing medications for dementia and emergency departments across the province of Ontario.

    • The analysis included 180,940 stroke survivors (mean age of 69, and 45% women) who had either an ischemic stroke or intracerebral hemorrhage and survived without dementia for at least 90 days.

    • The study population was matched 1 to 1 on age, sex, rural residence, neighborhood marginalization, hypertension, diabetes (including Type 1 and Type 2 together), high cholesterol, atrial fibrillation, heart failure and peripheral artery disease -; factors known to increase the risk of dementia.

    Source:

    American Heart Association

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  • CT scans may be better first step for evaluating chest pain

    CT scans may be better first step for evaluating chest pain

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    Previous studies have found less than 40% of patients with stable chest pain undergoing invasive coronary angiography are found to have obstructive coronary artery disease. Recent randomized clinical trials have demonstrated a benefit to using computed tomography angiography (CTA) first in evaluation of these patients, and a new study being presented at the American College of Cardiology Cardiovascular Summit lends credence to this strategy, finding that CT was associated with a higher likelihood of revascularization compared to other imaging modalities or no testing.

    Stable angina is a type of chest discomfort that occurs when the heart muscle needs more oxygen than usual-;such as during stress, exercise or cold weather-;but it’s not getting it, often due to blocked coronary arteries. Patients with stable angina are often treated with guideline-directed medical therapy and lifestyle changes but may also need a coronary revascularization procedure to restore adequate blood flow to resolve their symptoms.

    Right now, when a patient presents to their primary care physician or cardiologist with symptoms suspicious for angina, they are commonly referred for additional testing.”


    Markus Scherer, MD, Director of Cardiac CT and Structural Heart Imaging at Atrium Health-Sanger Heart & Vascular Institute and study’s senior author

    Between October 2022 and June 2023, researchers at Atrium Health-Sanger Heart & Vascular Institute in Charlotte, North Carolina, assessed 786 patients who had no prior diagnosis of coronary artery disease and underwent elective invasive coronary angiography (ICA) for the evaluation of suspected angina. The pre-ICA testing strategies were: no noninvasive testing with direct referral to ICA (44%), stress echocardiogram (3%), stress myocardial perfusion imaging (15%), stress MRI (2%) and coronary CTA (36%). The study cohort had a mean age of 66 years, was 63% male, 37% female, 81% White, 13% Black, 1% Asian, 1% Hispanic and 1% other.

    The researchers compared rates of subsequent revascularization between patients whose initial evaluation was coronary CTA versus stress testing or clinical judgement (no testing). The “CT first” strategy was associated with subsequent revascularization in 62% of patients compared to 34% for the combination of other modalities or direct ICA referral.

    The 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain suggests either non-invasive functional imaging or coronary CTA as the initial test without specifying a preference for one or the other.

    According to the researchers, there are a multitude of reasons health systems don’t currently use a CT first approach, including the availability of high-quality CT scanners; availability of qualified cardiac CT interpreting physicians; and challenges in transitioning to a newer approach after decades of pre-established patterns (i.e. stress testing). Furthermore, a CT first approach is predominately advocated for patients with unestablished coronary artery disease and does not apply to all, as some patient factors may reduce the accuracy and utility of coronary CTA. 

    “While care must be individualized, for patients with unknown or unestablished coronary artery disease, the transition to a ‘CT first’ strategy should be a high priority for cardiovascular care providers,” Scherer said. “The non-invasive approach has a lower risk and cost than a diagnostic heart catheterization and, for the CT approach-;but not stress testing-;provides information on the absence, presence and extent of coronary atherosclerosis and whether or not there are high risk plaques as well as vessel blockages, which helps streamline patient management and risk reduction.”

    Since coronary CTA is less expensive than both nuclear myocardial perfusion imaging and ICA, there is a direct cost saving to patients and third-party payers with the CT first approach, according to Scherer. From the perspective of a health system, the most financially efficient evaluation approach becomes more important during the transition to a value-oriented health care system.

    According to the authors, the study demonstrates “real world” credence to the randomized trials showing similar benefits to a “CT first” strategy and should promote increased adoption of this strategy for the evaluation of patients with chest pain and an unestablished history of coronary artery disease.

    “Cardiac catheterization labs are a capital and human resource intensive care environment. Using them for their maximum potential of treating disease, rather than diagnosing it, bring the highest yield for these resources to the health care system,” Scherer said.

    The full results of the study and other studies will be presented at the ACC Cardiovascular Summit 2024 in Washington, on February 1-3, 2024. The ACC Cardiovascular Summit 2024 will examine innovative strategies and emerging trends in CV care, assess operational efficiencies to enhance the effectiveness of the CV service line, and adopt customizable approaches that support economic sustainability.

    Source:

    American College of Cardiology

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  • Mechanically ventilated patients in intermediate care units of rural hospitals have higher death rates

    Mechanically ventilated patients in intermediate care units of rural hospitals have higher death rates

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    A new National Institutes of Health-supported study finds that patients receiving ventilator life support in the intermediate care units – a potentially less costly alternative for people not sick enough for the intensive care units (ICUs) but too ill for the general ward – of rural hospitals had significantly higher death rates than patients in the same type of unit at urban hospitals. The study also found that patients with respiratory failure in the ICUs at rural and urban hospitals fare similarly. Published in the journal Annals of the American Thoracic Society, this study highlights the need for more careful evaluations of patients with breathing problems who are assigned to intermediate care units.

    This study has important implications for rural hospitals when determining how to care for their sickest patients on mechanical ventilation, as rural hospitals tend to be smaller and less resourced. It emphasizes the need to assess whether rural intermediate care units can meet the complex demands of critically ill patients, and the importance of carefully evaluating the processes designed to care for them.”


    Gustavo Matute-Bello, M.D., deputy director for the Division of Lung Diseases at the National Heart, Lung, and Blood Institute (NHLBI), NIH

    The research team, led by Emily Harlan, M.D., a pulmonary and critical care physician at the University of Michigan, Ann Arbor, collected data from 2010 to 2019 on 2.75 million hospitalizations of Medicare patients (65 years or older) who were on respiratory support at rural and urban hospitals across the country. The researchers conducted separate analyses for patients admitted to the general, intermediate, and ICU wards, and another analysis of patients in all the wards combined.

    When they compared patients in all the wards, they found that those receiving mechanical ventilation in rural hospitals had significantly higher 30-day death rates than those in urban hospitals. However, when the researchers broke down the data by level of care, patients in the ICUs of rural and urban hospitals had a similar chance of dying. The difference in outcomes, the researchers discovered, was singularly explained by the higher mortality rates for patients in the rural intermediate care units – 37% died within 30 days compared to 31.3% in urban hospitals.

    When patients are admitted to a hospital, the least sick are taken to the general ward and the sickest go to the ICU. However, U.S. hospitals are increasingly shifting toward a model that incorporates intermediate care units, which use fewer resources and can be less expensive to operate than ICUs. While these units may help a rural hospital’s financial bottom line how rural patients fared in them compared to their urban counterparts, was largely unknown.

    “This study underscores the importance of learning more about how to best use intermediate care units and highlights the need to continue investing in rural hospitals to make sure all who need it have access to life-saving care,” said Harlan. “There is a common belief that rural hospitals may have a lower quality of care, but that’s not what we saw for the ICU patients in our study.”

    Source:

    NIH/National Heart, Lung and Blood Institute

    Journal reference:

    Harlan, E. A., et al. (2024) Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care. Annals of the American Thoracic Society. doi.org/10.1513/AnnalsATS.202308-684OC.

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  • Machine learning could personalize diuretic treatment for patients with acute decompensated heart failure

    Machine learning could personalize diuretic treatment for patients with acute decompensated heart failure

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    A recent study co-authored by Dr. Matthew Segar, a third-year cardiovascular disease fellow at The Texas Heart Institute and led by his research and residency mentor, University of Texas Southwestern Medical Center’s Dr. Ambarish Pandey, utilized a machine learning-based approach to identify, understand, and predict diuretic responsiveness in patients with acute decompensated heart failure (ADHF).

    The study “A Phenomapping Tool and Clinical Score to Identify Low Diuretic Efficiency in Acute Decompensated Heart Failure,” published in the prestigious Journal of American College Cardiology Heart Failure (JACC Heart Failure), leverages decades of clinical and registry datasets funded by the National Institutes of Health and American Heart Association.

    The researchers leveraged machine-learning-based approaches to develop a prediction tool called the BAN-ADHF score, which showed promising results in accurately predicting diuretic response. After validation in other clinical populations, implementing this tool could potentially lead to personalized strategies for effectively managing the congestion of patients hospitalized with ADHF.

    There remains a lack of agreement among experts regarding the most effective approach to address diuretic resistance in patients with heart failure who are stable hemodynamically and have an excess volume of fluid. It is generally recommended to optimize the dosage of loop diuretics before considering combination therapy; however, there is no consensus on how much the dosage should be increased before introducing another diuretic.

    “Inefficient diuretic response in hospitalized patients can hinder treatment progress and increase the risk of post-discharge rehospitalization and mortality. It’s crucial to identify individuals with low diuretic efficiency early on to tailor decongestion strategies and improve clinical outcomes,” according to Dr. Segar.

    ADHF is a public health issue that is becoming increasingly concerning. The disease results in emergency room visits, hospital admissions, and associated high healthcare costs. ADHF is characterized by the body having too much fluid, which often requires hospitalization or changing a patient’s current treatment plan.

    Today, a primary goal of treating ADHF is to relieve congestion using loop diuretic drugs. However, there is still uncertainty about the best dose of these agents to administer. Additionally, because of the heterogeneity of ADHF patients, a more personalized approach to predicting optimal dosing strategies is needed.” 


    Dr. Joseph G. Rogers, President and CEO of The Texas Heart Institute

    In the study, researchers from institutions across the United States utilized machine learning (ML) algorithms to identify subgroups of patients with acute heart failure based on their responsiveness to diuretic therapy. Specifically, the researchers developed a diuretic efficiency phenomapping approach for patients with ADHF by using publicly available and deidentified data from several clinical trials and registries, including DOSE, ROSE-AHF, CARRESS-HF, ATHENA-HF, ESCAPE, and the American Heart Association Precision Medicine Platform Get with the Guidelines-HF (GWTG-HF) registry. This participant-level pooled data enabled the investigators to develop a phenomapping approach and diuretic efficiency score. The patients within each subgroup shared similar characteristics but were clinically distinct from other subgroups, particularly in their response to diuretic therapy. In addition to differences in their diuretic response, the patient subgroups also had meaningfully different clinical outcomes, highlighting the prognostic utility of the phenogrouping approach. The investigators subsequently developed and validated the BAN-ADHF score to predict the probability of being in the phenogroup with the least diuretic response.

    “We know the BAN-ADHF score can accurately identify, characterize, and predict diuretic resistance among individuals with ADHF mathematically. Now we must take this medical knowledge and conduct a clinical study to evaluate whether implementing the BAN-ADHF score in our care protocols improves outcomes for patients hospitalized with acute decompensated heart failure,” shared Dr. Segar.

    Notably, the work described in this study received recognition from the National Institutes of Health’s National Heart, Lung, and Blood Institute (NHLBI) as a winning solution to the NHLBI Big Data Analysis Challenge: Creating New Paradigms for Heart Failure Research. The challenge encouraged the development of novel, open-source disease models to define subgroups of heart failure and support further advancements in managing the disease. Additionally, Dr. Segar received the American Heart Association’s Samuel A. Levine Early Career Clinical Investigator Award for his role in developing the phenomapping tool and the diuretic resistance clinical risk score. As part of the honor, he presented his research on “Development and Validation of a Phenomapping Tool To Identify Patients With Diuretic Resistance in Acute Decompensated Heart Failure: A Multi-Cohort Analysis” at the American Heart Association’s 2022 Scientific Sessions.

    Study collaborators included investigators from The Texas Heart Institute, Duke University School of Medicine, Cleveland Clinic, Houston Methodist DeBakey Heart and Vascular Center, University of Mississippi Medical Center, Baylor Scott and White Research Institute, St. Vincent Heart Center, The University of Texas Southwestern Medical Center, Ronald Reagan UCLA Medical Center, Institute for Precision Cardiovascular Medicine at the American Heart Association, Stony Brook University School of Medicine, Northwestern University School of Medicine, and University of Colorado.

    Source:

    Journal reference:

    Segar, M. W., et al. (2023). A Phenomapping Tool and Clinical Score to Identify Low Diuretic Efficiency in Acute Decompensated Heart Failure. JACC: Heart Failure. doi.org/10.1016/j.jchf.2023.09.029.

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