Cerebrovascular risk factors and their time-dependent effects on stroke survival in the EMMA cohort study

To investigate the time-dependent effects of traditional risk factors on functional disability in all-cause mortality post-stroke, we evaluated data from a long-term stroke cohort. Baseline cerebrovascular risk factors (CVRF) and functionality at 1 and 6 months were evaluated in survivors from a prospective stroke cohort using the modified Rankin scale (m-RS), which classifies participants as improvement of disability, unchanged disability (at least moderate), and worsening disability. Cox regression models considering baseline risk factors, medication use, and functionality 6 months after stroke were fitted to identify their time-dependent effects up to 12 years of follow-up. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) are presented. Among 632 survivors (median age 68, 54% male, 71% first-ever episode), age and functional disability (unchanged and worsening) 6 months after ischemic stroke had time-dependent effects on all-cause mortality risk up to 12 years of follow-up. The most impacting risk factors were unchanged (at least moderate) (HR, 2.99; 95%CI: 1.98-4.52) and worsening disability (HR, 2.85; 95%CI: 1.26-6.44), particularly in the first two years after a stroke event (Time 1: ≥6 mo to <2.5 y). Worsening disability also impacted mortality in the period from ≥2.5 to <7.5 years (Time 2) of follow-up (HR, 2.43 (95%CI: 1.03-5.73). Other baseline factors had a fixed high-risk effect on mortality during follow-up. Post-stroke and continuous medication use had a fixed protective effect on mortality. Functional disability was the main contributor with differential risks of mortality up to 12 years of follow-up.

A qualitative study on the current situation of hospital-institution-community comprehensive prevention of stroke / 中国实用护理杂志

Objective:To deeply explore the real work of primary, secondary and tertiary prevention of stroke in general hospitals, rehabilitation and pension institutions and community health service centers (stations), and to provide reference for improving the level of comprehensive prevention of stroke in the medical system.Methods:From July to November 2022, face-to-face semi-structured interviews with 18 medical staff in general hospitals, 10 medical staff in rehabilitation and pension institutions, and 8 medical staff in community health service centers (stations) were conducted by phenomenological research methods. Colaizzi 7-step analysis method was used to analyze the interview data, and Nvivo12 software was used to code the interview data.Results:Four themes were extracted: hospitals, institutions and communities all played an important role in the comprehensive prevention of stroke and actively cooperated with each other; the public was still lack of comprehensive prevention awareness and correct cognition of stroke; lack of professional medical resources hindered the development of comprehensive stroke prevention; incomplete collaborative mechanism of comprehensive prevention of stroke in hospitals, institutions and communities.Conclusions:In the current comprehensive prevention of stroke, there are still problems such as weak public awareness of prevention, insufficient professional medical resources, and imperfect coordination mechanism. In view of the advantages of medical institutions at all levels, it is necessary to clarify the responsibilities of the system at all levels and explore efficient and sustainable coordination mechanism, so as to improve the comprehensive prevention level of stroke in the medical system.

Popular knowledge of stroke in São Paulo: a cross-sectional study within the World Stroke Campaign

ABSTRACT BACKGROUND: Stroke is the second leading cause of death in Brazil and the main cause of disability. Inability to identify alarm signals causes delays in seeking emergency services, thereby leading to a worse prognosis. OBJECTIVES: To assess the population's knowledge of how to recognize and prevent stroke. DESIGN AND SETTING: Prospective cross-sectional study on data derived from a questionnaire that was administered during the 2016 World Stroke Campaign, launched in the city of São Paulo, Brazil. METHODS: Data on 806 interviewees were evaluated using descriptive statistics and univariate and multivariate analyses. RESULTS: Among all the interviewees, 52.1% knew how to conceptualize stroke; 70.07% knew someone who had suffered a stroke; and 29.03% listed three or more risk factors. Only 27.5% mentioned controlling high blood pressure as a preventive measure. In the event of witnessing a stroke, 57.8% would call the emergency service and 2.9% would check the timing. Less educated individuals were 5.6 times more likely (95% confidence interval, CI 3.45-9.02) to have poor knowledge of stroke, compared with the more educated group. Knowing someone who had had a stroke reduced the chances of not knowing the terms relating to the disease (odds ratio, OR = 0.56; 95% CI 0.4-0.78). CONCLUSIONS: Despite the severity and prevalence of stroke, the population still has little information on this disease. In this context, the importance of mounting campaigns to improve prevention and treatment and to contribute to healthcare policies becomes evident.

Prevención del stroke en fibrilación auricular. Hallazgos del registro GLORIA-AF / Stroke Prevention In Atrial Fibrillation. Findings From The Gloria-Af Registry

RESUMEN Introducción: El GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) es un registro internacional, prospectivo, en tres fases, para determinar la seguridad y eficacia del dabigatrán en pacientes con fibrilación auricular no valvular recientemente diagnosticada, en riesgo de stroke. La fase II empezó cuando el dabigatrán, el primer anticoagulante oral no antagonista de la vitamina K (NOAC) estuvo disponible. Objetivos: Describir los datos clínicos basales de la fase II en la población general y el seguimiento a 2 años de aquellos que recibieron dabigatrán. Material y Métodos: Se reclutaron un total de 15 644 pacientes, de los cuales 15 308 fueron elegibles y 4873 recibieron dabigatrán. Se analizaron las características de la fibrilación auricular, los hallazgos en el seguimiento y las enfermedades concomitantes. Los datos fueron analizados usando estadísticas descriptivas. Resultados: Del total de pacientes elegibles, el 45,5% eran mujeres, con una edad promedio de 71 (rango intercuartilo: 64-78) años. Los pacientes eran de Europa (47,9%), América del Norte (22,2%), Asia (20,1%), América Latina (6,0%) y Medio Oriente/ África (3,9%). La mayoría se encontraba en alto riesgo de stroke (CHA2DS2-VASc score >2; 86,1%); un 13,9% tuvieron riesgo moderado (CHA2DS2-VASc score >1). El 80,3% recibieron anticoagulantes orales; de ellos, el 47,9% recibieron NOAC y el 32,4%, antagonistas de la vitamina K (VKA); 12,0% recibieron agentes antiagregantes plaquetarios y el 7,6% no recibieron tratamiento antitrombótico. A 2 años de seguimiento, el 70,5% permanecieron en dabigatrán. Conclusiones: Los datos de la fase II del registro GLORIA-AF demostraron que, en FA no valvular, los NOAC han sido ampliamente adoptados en la práctica clínica y fueron más frecuentemente prescriptos que los VKA. No obstante, una gran proporción de pacientes en todo el mundo permanecieron sin tratamiento.

ABSTRACT Background: GLORIA-AF is a prospective, global, 3-phase registry program to determine the safety and effectiveness of dabigatran in patients with newly diagnosed non-valvular atrial fibrillation at risk of stroke. Phase II began when dabigatran, the first non-vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives: To describe phase II baseline clinical data in the general population and 2-year follow-up of those patients treated with dabigatran. Methods: A total of 15,644 patients were enrolled, 15,308 of whom were eligible and 4,873 received dabigatran. Atrial fibrillation disease characteristics, follow-up findings and concomitant diseases were collected. Data were analyzed using descriptive statistics. Results: Of the total eligible patients, 45.5% were female; median age was 71.0 (interquartile range: 64, 78) years. Patients were from Europe (47.9%), North America (22.2%), Asia (20.1%), Latin America (6.0%), and the Middle East/Africa (3.9%). Most had high stroke risk (CHA2DS2-VASc score ≥2; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc =1). Overall, 80.3% received oral anticoagulants, of whom 47.9% received NOACs and 32.4% vitamin K antagonists (VKA); 12.0% received anti-platelet agents; and 7.6% received no antithrombotic treatment. At 2-year follow-up, 70.5% remained on dabigatran. Conclusions: Data from GLORIA-AF phase II showed that in non-valvular AF, NOACs have been highly adopted in clinical practice, becoming more frequently prescribed than VKAs. Worldwide, however, a large proportion of patients remain undertreated.

The Role of Patent Foramen Ovale Closure in the Secondary Prevention of Cryptogenic Stroke: a Meta-Analysis Report

Abstract Background: Patent foramen ovale (PFO) closure has been compared to medical therapy for secondary prevention of recurrent cryptogenic stroke. Objectives: To produce an updated meta-analysis including only data from the primary analyses of clinical trials and to evaluate the role of PFO closure in the secondary prevention of recurrent stroke. Methods: Search in Medline (PubMed) and in ISI Web of Knowledge. Parameters under analysis and meta-analyses were: stroke, transient ischemic attack (TIA) and atrial fibrillation (AF). Comprehensive Meta-analysis Software V.2.0 (Biostat) was used. Random-effects analyses were carried out. A level of significance of 5% was used. Results: In this study six, randomized trials enrolling 3,750 patients were included. Unlike other published meta-analyses on the same topic, in this case, only clinical trial data, and not follow-up data, were used. PFO closure, as compared with medical therapy alone, demonstrated superiority in reducing the rate of recurrent stroke (risk ratio with PFO closure vs. medical therapy, 0.37; 95% confidence interval [CI], 0.17 to 0.78; p = 0.01). PFO closure did not offer a significant benefit in prevention of TIA (risk ratio with PFO closure vs. medical therapy, 0.96; 95% CI, 0.64 to 1.44; p = 0.85). Among patients assigned to closure group, an increased risk of atrial fibrillation was seen (risk ratio with PFO closure vs. medical therapy, 4.64; 95% CI, 2.38 to 9.01; p < 0.01). Conclusions: In patients with cryptogenic stroke who had a patent foramen ovale, a protective effect of closure was seen concerning the risk of recurrent stroke, but not regarding the prevention of TIA.

Dynamic alteration of risk factors for stroke in the population of Wanshoulu community of Beiijng Haidian district from 2011 to 2017 / 中国脑血管病杂志

Objective To evaluate the efficacy of stroke prevention project for screening community stroke population by analyzing the dynamic alteration of risk factors and the control levels for stroke in the Wanshoulu community from 2011 to 2017. Methods We retrospectively analyzed the database of the Wanshoulu community population of stroke screening in2011(n = 10 379),2013 (n = 2 364),2015 (n = 6 048) and 2017 (n = 3 497). The population in 2011 and 2013 were first screening population (covered rate reached 84. 7% in the population aged ≥40 years old), and the population in 2015 and 2017 were re-examination population. We analyzed the dynamic alteration in the proportion of eight risk factors of stroke (hypertension, diabetes, dyslipidemia, smoking, less physical exercise, atrial fibrillation, obesity, and family history), the awareness rate and the control rate of three risk factors(hypertension, diabetes, and dyslipidemia), and the risk categories of stroke from 2011 to 2017. Results Compared with the data in 2011 and 2013, the proportion of patients with six risk factors in 2015 and 2017, including hypertension(26.8% [1623/6 048], 27.2% [952/3 497] ta.30.9% [3 210/10 379], 33.7% [796/2 364]), atrial fibrillation (2.1% [124/6 048], 1.6% [57/3 497] vs. 6. 7% [691/10 379], 2.7% [64/2 364]), smoking (11.9% [718/6 048], 7. 7% [268/3 497] vs. 17. 8% [1 845/10 379], 14.5% [343/2 364]), dyslipidemia (15.3% [928/6 048], 15.0% [526/3 497] vs. 17. 5% [1814/10 379], 22.0[519/2 364]), less physical exercise (18.4% [1 112/6 048], 17. 1% [598/3 497] vs. 24. 1 % [2 497/10 379], 33.0% [780/2 364]), and obesity (12.7% [769/6 048], 5.4% [190/3 497] vs. 12.9% [1 337/10 379], 17.0% [403/2 364]), gradually decreased over the time(all P <0. 01). Meanwhile, the proportion of high-risk stroke population decreased (22. 9% [2 373/10 379], 19. 9% [470/2 364], 17. 9% [1 083/6 048], 17.0% [595/3 497]) in 2011, 2013, 2015 and 2017, respectively. χ2=158.331, P<0.01). Compared with that in 2011, the awareness rate and control rate of hypertension, diabetes mellitus, and dyslipidemia were all increased in 2017(all P<0.01). Conclusion Since the performance of stroke prevention project in 2011, the risk factors of stroke have been well controlled, and the proportion of high-risk stroke population has been decreasing.

Endovascular closure of patent foramen ovale: a critical appraisal of published trials / Fechamento endovascular do forame oval patente: análise crítica dos estudos publicados

ABSTRACT The treatment of cryptogenic stroke patients with a patent foramen ovale (PFO) is controversial. A critical review of these studies is presented. Methods A description of all trials comparing medical and endovascular treatment with closing devices is given. Additional pertinent studies are discussed to help construct a rational basis for treatment decisions. Results Initial negative trials evaluating PFO closure were followed by positive studies published in 2017 and 2018. All trials evaluated young patients (up to 60 years). Methodological problems are present in all trials including their open label construction. Most positive trials developed strategies to increase the percentage of patients with interatrial septal aneurysms or hypermobility and large right-to-left shunts. Even in these positive trials, large numbers of patients need to be treated to avoid one stroke. Atrial fibrillation occurred in 2-6% and other adverse effects related to the procedure and to the devices occurred in a substantial number of patients. Incomplete occlusion of the PFO is also frequent. Anticoagulant treatment has not been adequately studied as a therapeutic option. Conclusion Young patients with cryptogenic strokes seem to benefit from endovascular closure of a PFO in the presence of a large right-to-left shunt or an associated atrial septum aneurysm. For most other patients, a highly-individualized decision must be made, taking into account the low risk of recurrence in patients with a cryptogenic stroke attributable to a PFO, the high numbers needed to treat and the risks related to the procedure.

RESUMO O tratamento de pacientes com infarto cerebral criptogênico e forame oval patente (FOP) é controverso. Uma revisão crítica destes estudos é apresentada. Métodos São descritos em detalhes os estudos comparando tratamento médico com o uso de próteses de oclusão do FOP após infarto cerebral. Discutem-se outros estudos pertinentes para ajudar na tomada racional de decisões terapêuticas individualizadas. Resultados Estudos iniciais avaliando fechamento endovascular com próteses foram negativos, porém seguidos de outros estudos com resultados positivos em 2017 e 2018. Somente pacientes até 60 anos foram estudados. Os estudos apresentam vários problemas metodológicos, incluindo sua natureza aberta. A maioria dos estudos positivos desenvolveu estratégias para aumentar o percentual de pacientes com risco aumentado de recorrência, especificamente grandes shunts direita-esquerda e aneurismas/hipermobilidade do septo interatrial. Mesmo estes estudos positivos revelaram um alto NNT (número de pacientes tratados para evitar um evento de desfecho). Fibrilação atrial ocorreu em 2-6 % dos pacientes tratados. Outras complicações relacionadas ao procedimento e às endopróteses e ainda fechamento incompleto do FOP foram também frequentes. Anticoagulantes poderiam constituir estratégia alternativa de tratamento clínico, mas não foram adequadamente estudados. Conclusão Pacientes jovens com infartos criptogênicos parecem beneficiar-se de oclusão endovascular do FOP na presença de grandes shunts e principalmente aneurismas ou hipermobilidade de septo interatrial. Para a maioria dos outros pacientes, uma decisão altamente individualizada deve ser tomada, considerando o baixo risco de recorrência dos infartos atribuíveis ao FOP, o ato NNT e os riscos inerentes ao procedimento.

Construction of national stroke center network system / 国际生物医学工程杂志

Stroke is one of the main causes of mortality, long-term physical and cognitive impairment in China. In order to meet the challenge, Stroke Prevention and Treatment Project of the National Health Commission(SPTPC) was established in April 2011 in the Ministry of Health. In 2016, SPTPC issued a work plan of stroke center hospital. In order to shorten the time of pre-hospital, the SPTPC established the stroke center network, stroke map and stroke green channel to create "the three 1-hour gold rescue circle" to form a hierarchical stroke diagnosis and treatment system. The current construction of the Chinese Stroke Center is divided into two levels and four layers. As of December 31, 2018, SPTPC has certified a total of 310 advanced stroke centers, including 30 demonstration advanced stroke centers and 280 advanced stroke centers, and 127 stroke prevention centers, including 85 demonstration stroke prevention centers and 42 stroke prevention centers. The median time from admission to intravenous thrombolysis (DNT) at the advanced stroke center was decreased by 13.2% (53 min vs. 46 min) in the fourth quarter of 2018 as compared with that in the first quarter of 2017.The national thrombolytic rate of acute ischemic stroke was increased 3.24 times (1.78% vs. 0.42%) in 2017 compared that in 2010. In the next step, SPTPC will vigorously promote the construction of stroke centers and graded diagnosis and treatment mechanisms, consolidate quality control and standardization, increase the scope of influence of mobile stroke and remote diagnosis and treatment, and further improve the construction of stroke center systems with Chinese characteristics.

Construction of national stroke center network system / 国际生物医学工程杂志

Stroke is one of the main causes of mortality, long-term physical and cognitive impairment in China. In order to meet the challenge, Stroke Prevention and Treatment Project of the National Health Commission (SPTPC) was established in April 2011 in the Ministry of Health. In 2016, SPTPC issued a work plan of stroke center hospital. In order to shorten the time of pre-hospital, the SPTPC established the stroke center network, stroke map and stroke green channel to create "the three 1-hour gold rescue circle" to form a hierarchical stroke diagnosis and treatment system. The current construction of the Chinese Stroke Center is divided into two levels and four layers. As of December 31, 2018, SPTPC has certified a total of 310 advanced stroke centers, including 30 demonstration advanced stroke centers and 280 advanced stroke centers, and 127 stroke prevention centers, including 85 demonstration stroke prevention centers and 42 stroke prevention centers. The median time from admission to intravenous thrombolysis (DNT) at the advanced stroke center was decreased by 13.2％ (53 min vs. 46 min) in the fourth quarter of 2018 as compared with that in the first quarter of 2017.The national thrombolytic rate of acute ischemic stroke was increased 3.24 times (1.78％ vs. 0.42％) in 2017 compared that in 2010. In the next step, SPTPC will vigorously promote the construction of stroke centers and graded diagnosis and treatment mechanisms, consolidate quality control and standardization, increase the scope of influence of mobile stroke and remote diagnosis and treatment, and further improve the construction of stroke center systems with Chinese characteristics.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack / Indicadores de desempenho do programa "Get With The Guidelines®-Stroke" em pacientes com ataque isquêmico transitório

ABSTRACT Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. Objective: The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. Methods: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. Results: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. Conclusions: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

RESUMO O "Get With The Guidelines®-Stroke (GWTG-S)" é um programa hospitalar criado para melhorar os cuidados em pacientes com AVC ao promover a adesão às diretrizes. Dez a quinze porcento dos pacientes com ataque isquêmico transitório terão um AVC em 3 meses, sendo que muitos não recebem intervenções de prevenção secundária recomendadas. Objetivo: Avaliar a adesão aos indicadores de qualidade do programa GWTG em pacientes com ataque isquêmico transitório. Métodos: Este estudo retrospectivo observacional avaliou pacientes consecutivos admitidos em um centro de AVC com suspeita de ataque isquêmico transitório ou AVC isquêmico agudo de agosto/2008 a dezembro/2013. Seis indicadores de qualidade aplicáveis tanto ao ataque isquêmico transitório quanto ao AVC isquêmico agudo foram analisados e comparados entre os grupos. Resultados: Um total de 357 pacientes com ataque isquêmico transitório e 787 pacientes com AVC isquêmico agudo foram avaliados. O uso de antiagregante dentro das primeiras 48 horas da admissão, liberação na alta com anticoagulante para fibrilação atrial e aconselhamento para cessação do tabagismo foram similares entre os grupos. No grupo com ataque isquêmico transitório, o uso de antiagregante na alta hospitalar, o tratamento com estatina e a educação sobre o AVC foram observados menos frequentemente quando comparados ao grupo de pacientes com AVC isquêmico agudo. Conclusões: A adesão a alguns dos indicadores de qualidade do programa GWTG-S foi mais baixa em pacientes com ataque isquêmico transitório quando compara a pacientes com AVC isquêmico agudo. Medidas devem ser tomadas para reforçar a importância dessas intervenções em pacientes admitidos com ataque isquêmico transitório.

A comparison of dabigatran and warfarin for stroke prevention in elderly Asian population with nonvalvular atrial fibrillation: An audit of current practice in Malaysia

Introduction: Atrial fibrillation (AF) is the most commoncardiac arrhythmia with significant morbidity and mortalityin relation to thromboembolic stroke. Our study aimed toevaluate the safety and efficacy of dabigatran in strokeprevention in elderly patient with nonvalvular AF with regardto the risk of ischemic stroke and intracranial haemorrhage(ICH) in real-world setting.Methods: A retrospective cohort study of 200 patients ondabigatran and warfarin from January 2009 till September2016 was carried out. Data were collected for 100 patients ondabigatran and 100 patients on warfarin.Results: The mean follow-up period was 340.7±322.3 daysfor dabigatran group and 410.5±321.2 days for warfaringroup. The mean time in therapeutic range (TTR) was52±18.7%. The mean CHA2DS2 -VASc score for dabigatrangroup was 4.4±1.1 while 5.0±1.5 for warfarin group. None indabigatran group experienced ischemic stroke compared toone patient in warfarin group (p=0.316). There was onepatient in dabigatran group suffered from ICH compared tonone in warfarin group (p=0.316). Four patients in warfaringroup experienced minor bleeding, while none fromdabigatran group (p=0.043).Conclusion: Overall bleeding events were significantly lowerin dabigatran group compared to warfarin group. In thepresence of suboptimal TTR rates and inconveniences withwarfarin therapy, non-vitamin-K antagonist oralanticoagulants (NOAC) are the preferred agents for strokeprevention in elderly Asian patients for nonvalvula

Quality of Anticoagulation with Warfarin in Korean Patients with Atrial Fibrillation and Prior Stroke: A Multicenter Retrospective Observational Study

BACKGROUND AND PURPOSE: The quality of anticoagulation is critical for ensuring the benefit of warfarin, but this has been less well studied in Korean ischemic stroke patients with atrial fibrillation (AF). METHODS: This study retrospectively analyzed the data of patients who had an AF-related ischemic stroke and were treated with long-term warfarin therapy in 16 Korean centers. The quality of warfarin therapy was primarily assessed by the time in therapeutic range [TTR; international normalized ratio (INR), 2.0–3.0] and additionally by the proportion of INR values within the therapeutic range. RESULTS: The long-term warfarin-treated cohort comprised 1,230 patients. They were aged 70.1±9.7 years (mean±SD), 42.5% were female, and their CHA₂DS₂-VASc score was 4.75±1.41. The TTR analysis included 33,941 INR measurements for 27,487 months: per patients, 27.6 (SD, 22.4) INR measurements for 22.4 (SD, 12.9) months. The mean TTR of individual patients was 49.1% (95% confidence interval, 47.9–50.3%), and the TTR quartiles were 64.5%. None of the 16 centers achieved a mean TTR of >60%. Of all INR measurements, 44.6% were within the therapeutic range, 41.7% were 3.0. CONCLUSIONS: In Korean ischemic stroke patients who had AF, the quality of warfarin therapy was low and might be inadequate to effectively prevent recurrent stroke or systemic embolism.

Practice Preferences on Dabigatran and Rivaroxaban for Stroke Prevention in Patients with Non-valvular Atrial Fibrillation

OBJECTIVE: Prescription rate of dabigatran and rivaroxaban, which are the direct oral anticoagulants (DOAC), has increased. We have analyzed the prescription trend and medication use of dabigatran and rivaroxaban in patients with non-valvular atrial fibrillation (NVAF). METHODS: It was retrospectively studied from September 2012 to April 2014 using the electronic medical records and the progress notes. Patients with NVAF (n=424) were evaluated on the medication use, prescribing preferences, adverse drug reactions (ADRs) and the availability of prescription reimbursement of dabigatran (n=210) and rivaroxaban (n=214). RESULTS: Dabigatran was prescribed higher than rivaroxaban (23.3% versus 7.5%, p<0.001) in the neurology department, but rivaroxaban was prescribed higher compared to dabigatran in the cardiology department (87.4% versus 74.3%, p<0.001). Dabigatran was prescribed more than rivaroxaban in high risk patients with CHADS2 score ≥ 3 (44.3% versus 31.3%, p=0.006). Dabigatran patients seemed to have more ADRs than patients with rivaroxaban (25.2% versus 11.2%, p<0.001), but no serious thrombotic events and bleeding were found. Only 35.6% (n=151) were eligible for prescription reimbursement by the National Health Insurance (NHI). Bridging therapy (86, 31.5%) and direct-current cardioversion (57, 20.2%) were main reasons of ineligibility for reimbursement. CONCLUSION: Prescription preferences were present in choosing either dabigatran or rivaroxaban for patients with NVAF. Inpatient protocols and procedures considering patient-factors in NVAF need to be developed.

Percutaneous left atrial appendage Closure for Thromboembolic Prevention in atrial Fibrillation / Cierre percutáneo de la orejuela izquierda para prevención tromboembólica en fibrilación auricular

Background: Atrial fibrillation (AF) produces a five-fold increase in the risk of stroke, and the exclusion of the left atrial appendage (LAA), the main source of thrombi, is an interesting therapeutic option in patients with contraindication for oral anticoagulation. Objectives: The goal of this study was to evaluate the initial experience, immediate results and outcome at 45 days of percutaneous closure of the LAA in patients with AF and high risk of thromboembolic events, in whom chronic oral anticoagulation was contrain-dicated. Methods: Twenty-two patients with non-valvular AF and a CHA2DS2-Vasc ≥2 in whom there was contraindication or impossibility of long-term oral anticoagulation underwent percutaneous closure of the LAA with the WATCHMANT device. The patients were evaluated 45 days after the procedure by clinical assessment and transesophageal echocardiography. Results: The implant was successful in 21 of 22 patients (95.4%). Median (interquartile range) age and CHA2DS2-VASc and HAS-BLED scores were 76 years (IQR 14.5), 5 (IQR 1.5) and 4 (IQR 1), respectively. Three (13.6%) periprocedural complications were observed: one cardiac tamponade requiring surgery, one concealed major bleeding and one pseudoaneurysm of the femoral artery. No device-related complications or thromboembolic events were observed during the 45-day follow-up. The LAA was adequately excluded in 95% of the cases. Conclusions: In our initial experience, the procedure is feasible, with an acceptable risk, and can be considered a therapeutic option in patients with AF and high thromboembolic risk who cannot receive oral anticoagulation.

Introducción: La fibrilación auricular (FA) incrementa cinco veces el riesgo de accidente cerebrovascular y la orejuela auricular izquierda (OI) es la principal fuente de formación de trombos, por lo que su exclusión se presenta como una alternativa terapéutica interesante en pacientes con contraindicación para la anticoagulación oral. Objetivos: Evaluar la experiencia inicial, los resultados del implante y la evolución a los 45 días del cierre percutáneo de la OI en pacientes con FA de riesgo tromboembólico alto en los cuales no podía emplearse la anticoagulación oral crónica. Material y métodos: Veintidós pacientes con FA no valvular y CHA2DS2-Vasc ≥2 en los que la anticoagulación a largo plazo estaba contraindicada o era impracticable fueron sometidos al cierre percutáneo de la OI con el dispositivo WATCHMAN®. Los pacientes fueron evaluados a los 45 días mediante control clínico y con ecocardiografía transesofágica. Resultados: El implante fue exitoso en 21 de los 22 pacientes (95,4%). Las medianas (rango intercuartil) de edad, CHA2DS2-VASc y HAS-BLED fueron 76 años (RIC 14,5), 5 (RIC 1,5) y 4 (RIC 1), respectivamente. Se observaron 3 (13,6%) complicaciones periprocedimiento: un taponamiento que requirió revisión quirúrgica, un sangrado mayor oculto y un seudoaneurisma femoral. Durante el seguimiento a 45 días no se observaron complicaciones relacionadas con el dispositivo ni eventos tromboembólicos. En el 95% de los casos, la OI se encontraba adecuadamente excluida. Conclusiones: En nuestra experiencia inicial, el procedimiento es factible con un riesgo aceptable, constituyéndose en una alternativa terapéutica en pacientes con FA de riesgo tromboembólico alto que no pueden recibir anticoagulantes orales.

Application of New Oral Anticoagulants: Prevention of Stroke in Patients with Nonvalvular Atrial Fibrillation / 대한내과학회지

Only anticoagulation has been shown to reduce atrial fibrillation-related deaths. Vitamin K antagonists are difficult to use due to their narrow therapeutic range, unpredictable response, requirement for frequent coagulation monitoring, frequent dose adjustment, slow onset-offset, and numerous drug-drug and drug-food interactions. New oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, and apixaban have been developed and are available in Korea, and edoxaban was shown to be effective and safe, also. NOACs showed better pharmacodynamics with predictable serum concentrations and effects, and no requirement for coagulation monitoring. These drugs have been shown to be more effective and safer than warfarin for prevention of stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation. Broad, appropriate, and aggressive use of NOACs would improve the results of treatment in patients with nonvalvular atrial fibrillation in Korea.

The predictive model of carotid angiopathy set from randomly sampled community data / 中华急诊医学杂志

Objective To establish a practical and effective predictive model for predicting carotid plaque/thickened intima,and to provide a novel perspective for stroke screening.Methods A retrospective analysis of the community screening data collected from September 2012 to March 2013 was performed.The data of blood pressure,serum lipid profile and fasting blood glucose and ultrasonographic checks of carotid artery were documented.One thousand subjects were randomly sampled from totally 14 226 individuals and divided into 2 groups according to the presence of carotid plaque/thickened intima.Analysis of relevant data of subjects with Logistic regression were performed.Predictive model was established according to the odds ratio for each risk factor and evaluated by C statistics.Results In the randomly sampled 1000 subjects,164 ones were found to be with carotid plaque/thickened intima.The mean age was (60.23 ± 10.09) years old,110 (67.1％) were male.Smoker,hypertension,angina pectoris,diabetes and hyperlipidemia were seen more often in the subjects with carotid plaque/thickened intima.Logistic regression analysis showed the independent risk factors for carotid plaque/thickened intima included advanced age (OR =1.15,95％ CI:1.12-1.84,P＜0.01),male (OR=3.97,95％CI:2.49-6.33,P＜0.01),smoking (OR=1.80,95％CI:1.24-2.56,P =0.002),diabetes (OR =1.80,95％ CI:1.15-2.98,P =0.012),hypertension (OR =2.82,95％ CI:1.15-2.98,P ＜ 0.01),high total cholesterol level (OR =1.63,95％ CI:1.31-2.02,P ＜ 0.01) and high LDL-C (low density lipoprotein-cholesterol) level (OR =1.70,95 ％ CI:1.35-2.14,P ＜ 0.01).The advanced age was found to be the strongest predictive factor in this model.The C statistics of this model is 0.804,which overweighs other models previously reported.The optimal cutoff point for prediction was 3.5,with a sensitivity of 0.713 and a specificity of 0.757.Conclusion An practical and effective model for predicting carotid plaque/thickened intima established from sampling data of community residents is favorable for both stroke screening and primary stroke prevention.