ACIDENTE VASCULAR CEREBRAL E HIPERTENSÃO: RELAÇÃO, METAS E RECORRÊNCIA / STROKE AND HYPERTENSION: RELATIONSHIP, GOALS AND RECURRENCE

O acidente vascular cerebral (AVC) é uma das principais causas de morte, incapacidade e demência. A hipertensão arterial (HA) é o principal fator de risco para o AVC isquêmico ou hemorrágico demonstrando uma relação direta com os níveis pressóricos. O manejo da pressão arterial (PA) em adultos com AVC é complexo e desafiador devido a suas causas heterogêneas e suas consequências hemodinâmicas. Serão discutidas as recomendações de diretrizes no manuseio da HA na vigência de um AVC agudo, na prevenção e na recorrência.

Stroke is a major cause of death, disability and dementia. Hypertension is the main risk factor for ischemic or hemorrhagic strokes, demonstrating a direct relationship with blood pressure (BP) levels. The management of BP in adults with stroke is complex and challenging due to its heterogeneous causes and its hemodynamic consequences. Recommendations of guidelines on the management of hypertension during acute stroke, prevention and recurrence will be discussed.

The role of left atrial enlargement and age in the prediction of recurrence in embolic strokes of undetermined source / El papel del crecimiento auricular izquierdo y la edad como predictores de recurrencia en infarto cerebral embólicos de origen indeterminado

Abstract Objectives: Left atrial disease is an independent risk factor for ischemic stroke and can be used to predict atrial fibrillation (AF). We examine whether left atrial enlargement (LAE) could predict stroke recurrence in patients with embolic stroke of undetermined source (ESUS). Materials and methods: Sixty-four patients with a confirmed diagnosis of ESUS were followed for a median of 22 months. Clinical data and echocardiogram findings were recorded. The echocardiogram interpretation was performed centrally and blindly. The Brown ESUS – AF score was used to categorize patients into high (human resource planning [HRP]: score > 2) and low-risk patients (non-HRP score 0-1). Stroke recurrence was the primary outcome. Results: The median age was 62 years (range: 22-85 years); and 33 (51.6%) were men. The median initial NIHSS score was three points (range: 0-27). Twelve (18.8%) patients were categorized as HRP. We found a significant tendency toward recurrence among HRP versus non-HRP patients. Three (25%) HRP versus 2 (3.8%) non-HRP experienced recurrence (OR: 8.3 95% CI 1.2-57; p=0.042); this association was related to severe atrial dilatation (OR: 14.5 95% CI 0.78-277, p = 0.02) and age > 75 years (OR: 12.7 95% CI 1.7-92.2, p = 0.03). We found no differences in recurrence in a univariate analysis. Conclusions: Patients with severe LAE who are 75 years old or older have a significant tendency to experience stroke recurrence.

Resumen Objetivos: La patología atrial izquierda es factor de riesgo independiente para infarto cerebral y puede utilizarse para predecir fibrilación auricular. Examinamos si el crecimiento aurícular izquierdo puede predecir recurrencia en pacientes con infarto embolico de origen indeterminado (ESUS). Materiales y métodos: Sesenta y cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos por una mediana de seguimiento de 22 meses. Registramos los datos clínicos y ecocardiográficos. La interpretación ecocardiográfica fue centralizada y cegada. La escala de Brown ESUS – AF fue utilizada para categorizar a los pacientes en riesgo alto (HRP puntaje > 2) y bajo riesgo (no-HRP: puntaje 0-1). El descenlace primario fue recurrencia de infarto cerebral. Resultados: Mediana de edad fue de 62 años (rango: 22-85 años); 33 (51.6%) fueron hombres. La mediana inicial de la escala de NIHSS fue de 3 putnos (rango de 0 a 27). 12 (18.8%) pacientes fueron de alto riesgo (HRP) y 52 (81.3%) de bajo riesgo (non- HRP). El grupo HRP mostró tendencia significatica hacia mayor recurrencia. Tres (25%) HRP versus 2 (3.8%) no-HRP experimentaron recurrencia (OR: 8.3 IC 95% 1.2-57; p = 0.042); esta asociación se relacionó con dilatación auricular severa (OR: 14.5 IC 95% 0.78-277, p = 0.02) y edad > 75 años (OR: 12.7 IC 95% 1.7-92.2, p = 0.03). En el análisis multivarioado, no encontramos significativas. Conclusiones: El crecimiento auricular izquierdo severo y la edad mayor de 75 años mostraron tendencia significativa a recurrencia de infarto cerebral.

Value of CHADS-VASc score in predicting stroke recurrence in first-ever ischemic stroke survivors without atrial fibrillation / 南方医科大学学报

OBJECTIVE@#To test the performance of CHADS-VASc score in predicting stroke recurrence in first-ever ischemic stroke survivors without atrial fibrillation (AF).@*METHODS@#A total of 768 patients were included in this study, including 475 male (61.85%) and 293 female patients (38.15%) with a mean age of 61.52±12.59 years (17-90 years). The baseline information of the patients was collected by face-to-face questionnaire survey and electronic medical record review, and their follow-up information was collected by telephone follow-up once every 3 months. Chi-square test and Wilcoxon rank sum test were used to compare the baseline characteristics between the patients regularly followed up and those withdrawn from the study. The area under the ROC curve (AUC), sensitivity, specificity, positive likelihood ratio and other indicators of CHADS-VASc score were determined, and C-index based on Cox proportional hazards model was used to evaluate the performance of CHADS- VASc score in predicting the risk of stroke recurrence in patients at different time points during the follow-up.@*RESULTS@#The 1-year, 3-year, and 5-year recurrence rate of stroke was 10.59%, 20.45%, and 29.46% in these patients, respectively. The AUC value, Optimal Operating Point (OOP) and the corresponding positive likelihood ratios (LR+) for predicting stroke recurrence were 0.558 (95%: 0.492-0.624), 4.5, and 1.256 at 1 year; 0.574 (95%: 0.517-0.630), 4.5, and 1.397 at 3 years; and 0.604 (95%: 0.548-0.661), 4.5, and 1.655 at 5 years, respectively. Sensitivity analysis of congestive heart failure showed that the predictive effect of CHADS-VASc score was basically unchanged.@*CONCLUSIONS@#CHADS-VASc score can be used to predict the 3-year and 5-year risk of stroke recurrence in first-ever ischemic stroke survivors without AF. The score has a better prediction ability for long-term stroke recurrence, but the prediction value remains low, suggesting the need to further improve the score or establish a new score for predicting stroke recurrence.

Prevalence, risk factors and secondary prevention of stroke recurrence in eight countries from south, east and southeast asia: a scoping review

Introduction: In most Asian countries, stroke is one of themajor causes of mortality. A stroke event is life-changing forstroke survivors, which results in either mortality ordisability. Therefore, this study comprehensively focuses onprevalence, risk factors, and secondary prevention forstroke recurrence identified in South, East, and SoutheastAsian countries. Methods: This scoping review uses themethodological framework of Arksey and O’Malley. Acomprehensive search of academic journals (English) onthis topic published from 2007 to 2017 was conducted. Atotal of 22 studies were selected from 585 studies screenedfrom the electronic databases.Results: First-year stroke recurrence rates are in the rangeof 2.2% to 25.4%. Besides that, modifiable risk factors aresignificantly associated with pathophysiological factors(hypertension, ankle-brachial pressure index, atherogenicdyslipidaemia, diabetes mellitus, metabolic syndrome, andatrial fibrillation) and lifestyle factors (obesity, smoking,physical inactivity, and high salt intake). Furthermore, age,previous history of cerebrovascular events, and strokesubtype are also significant influence risk factors forrecurrence. A strategic secondary prevention method forrecurrent stroke is health education along with managingrisk factors through a combination of appropriate lifestyleintervention and pharmacological therapy.Conclusion: To prevent recurrent stroke, health interventionshould be geared towards changing lifestyle to embody ahealthier approach to life. This is of great importance topublic health and stroke survivors’ quality of life.

Evaluating the relationship between intracranial atherosclerotic plaque stability and stroke recurrence risk with high-resolution MRI / 中国脑血管病杂志

Objective To investigate the relationship between intracranial atherosclerotic plaque stability and stroke recurrence risk.Methods Forty-eight patients with acute ischemic stroke caused by intracranial atherosclerosis in Guangdong Province Hospital of TCM were analyzed retrospectively.After the Essen Stroke Risk Scale (ESRS) was used to assess the risk factors for the patients,they were divided into either an ESRS ≥3 group (n=21 in the high-risk recurrence group) or an ESRS <3 group (n=27 in the low-risk recurrence group).Both groups of patients underwent high-resolution MR imaging (HR-MRI) examinations of the intracranial guilty vessels (basilar artery or unilateral middle cerebral artery).According to the signal intensity of HR-MRI on the T1-weighted imaging,T2-weighted imaging,and T1 fat suppression sequences,the intracranial atherosclerotic stable plaques and unstable plaques were distinguished.The stabilization of intracranial atherosclerotic plaques was compared in patients of both groups.Results There were significant differences in the age and incidences of hypertension,diabetes mellitus,and unstable plaques in patients of both groups (P<0.05).Further multivariate logistic regression analysis of the four factors showed that the age,hypertension,diabetes,and intracranial atherosclerotic unstable plaques were the high-risk factors for recurrent ischemic stroke (ORs,87.114,159.423,8.942,and 11.551,respectively;95%CIs 4.218-1 799.078,3.235-7 855.957,1.054-75.857,and 1.011-132.043,respectively;all P<0.05).Conclusion In addition to the traditional risk factors such as age,hypertension,and diabetes,the intracranial atherosclerotic unstable plaque is an independent risk factor for high-risk recurrence of ischemic stroke.

Left atrial appendage occlusion with Amplatzer Cardio Plug is an acceptable therapeutic option for prevention of stroke recurrence in patients with non-valvular atrial fibrillation and contraindication or failure of oral anticoagulation with acenocumarol / La oclusión de la orejuela izquierda con Amplatzer Cardio Plug es una terapia aceptable para prevención del ACV isquémico en pacientes con fibrilación auricular y contraidicación o falla terapéutica con acenocumarol

ABSTRACT Left atrial appendage occlusion (LAAO) appears as a therapeutic option for some atrial fibrillation patients not suitable for oral anticoagulation because an increased hemorrhagic risk or recurrent ischemic events despite anticoagulant treatment. Methods Report of consecutive atrial fibrillation patients treated with LAAO with Amplatzer Cardio Plug because contraindication or failure of oral anticoagulation with acenocumarol. CHA2DS2VASC, HAS-BLED, NIHSS, mRS, procedural complications and outcome were assessed. Seven patients (73 ± 6 year-old) were treated after intracerebral (n = 5) and gastrointestinal (n = 1) hemorrhages or ischemic stroke recurrence while on acenocumarol (n = 1). Results Mean follow up was 18 months. Baseline CHA2DS2Vasc y HAS-BLED scores were 5.6 ± 0.7 and 4.1 ± 0.3 respectively. There were no strokes or deaths. There was only one non-serious adverse event. Conclusion LAAO with ACP appears as a feasible therapeutic option for stroke prevention in patients with atrial fibrillation and failure or contraindication to acenocumarol.

RESUMEN La oclusión de la orejuela auricular izquierda (OOAI) es una opción terapéutica en pacientes con fibrilación auricular y alto riesgo hemorrágico o recurrencia de accidente cerebrovascular isquémico (ACVi) a pesar del tratamiento anticoagulante. Métodos Reporte de pacientes con fibrilación auricular y contraindicación o fallo terapéutico con acenocumarol tratados con OOAI. Se evaluaron escalas CHA2DS2VASC, HAS-BLED, NIHSS y mRS, complicaciones procedurales y resultados. Resultados Siete pacientes (73 ± 6 años) fueron tratados luego de sufrir hemorragia cerebral (n = 5), gastrointestinal (n = 1) o ACVi recurrente a pesar del tratamiento con acenocumarol. Las escalas CHADS2VASC y HAS-BLED fueron 5.6 ± 0.7 y 4.1 ± 0.3 respectivamente. Luego de un seguimeinto promedio fue de 18 meses (3-50) no se registraron ACVi o muertes. Se registró sólo un evento adverso no serio. Conclusión La OOAI es una opción terapéutica factible para prevenir ACVi en pacientes con fibrilación auricular y fallo o contraindicación para recibir acenocumarol.

Effect of 20 mg/day Atorvastatin: Recurrent Stroke Survey in Chinese Ischemic Stroke Patients with Prior Intracranial Hemorrhage

BACKGROUND AND PURPOSE: Treatment with atorvastatin (80 mg) in stroke secondary prevention for patients with prior intracranial hemorrhage (ICH) has been associated with a higher frequency of ICH. The aim of this study was to determine whether 20 mg/day atorvastatin is linked to stroke recurrence in Chinese ischemic stroke patients with prior ICH. METHODS: A single-center retrospective cohort study was conducted, involving 354 cases from 395 Chinese in-patients who had ischemic stroke with prior ICH history in Beijing Chaoyang hospital from May 1, 2005 to October 31, 2010. Survivors were followed by telephone interviews for 12-60 months. Cox regression and Kaplan-Meier plot analysis were used to evaluate the effect of 20 mg/day atorvastatin on cerebral infarction and ICH recurrence. RESULTS: The overall rate of stroke recurrence was lower in the 20 mg/day atorvastatin group (chi2=6.687, p=0.022) than in the control group. The incidence of cerebral hemorrhage was increased by 20 mg/day atorvastatin for ischemic stroke cases with a history of ICH compared to those not receiving the drug, but the difference was not significant [hazard ratio (HR)=1.097, 95% confidence interval (CI)=0.800-1.243, p=0.980]. The incidence of ischemic stroke recurrence was significantly reduced in subjects receiving atorvastatin (HR=0.723, 95% CI=0.578-0.862, p=0.028), and the mean duration of all stroke recurrences was significantly prolonged, compared with those not exposed to the drug (chi2=5.351, p=0.021). The mean duration of ICH recurrence appeared to have shortened with atorvastatin, but the difference was not significant (chi2=0.680, p=0.480), and the mean duration of cerebral infarction recurrence was significantly prolonged (chi2=8.312, p=0.004). CONCLUSIONS: Medication with 20 mg/day atorvastatin may be beneficial in reducing ischemic stroke recurrence in ischemic stroke patients with a history of ICH and is not associated with an increased risk of ICH recurrence.

Factores predicoores de recurrencia ictal. estudio comunitario / Predictive Factors of ictal recurrency . Communitary study

La recurrencia del ictus es causa directa de morbimortalidad, discapacidad, minusvalía e institucionalización prolongada entre los sobrevivientes a un primer evento ictal. Estimar que factores de riesgo presentan mayor valor para los eventos recurrentes, permite establecer medidas de prevención secundaria y terciaria, más individualizadas y eficientes. Se realizó un estudio poblacional analítico y prospectivo en pacientes sobrevivientes a un primer evento ictal isquémico pertenecientes al área de salud del policlínico Cristóbal Labra en el período comprendido entre enero del 2004 y enero del 2006. Se logró un seguimiento efectivo en 289 pacientes por 24 meses. Predominó el sexo masculino con 161 casos. El grupo etáreo más afectado fue el de 65 a 79 años. Se registró un total de 39 casos de ictus recurrentes para una incidencia acumulada de 0.13. Los factores de riesgo que mostraron mayor valor para el ictus recurrente fueron el hábito de fumar (OR: 1.03,IC 95% 0.60-1.78,p :0.05) hipertensión arterial (OR: 2.94, IC95%1.00-8.67, p:0,00), cardiopatía isquémica (OR:1.95,IC95%:0.76-3.02,p:0.03), la hiperlipoproteinemia (OR:2.28, IC95%-1.46-3.55,p:0.00), ATI previo, Diabetes Mellitus y la enfermedad arterial peri-férica. Las formas clínicas más relacionadas con el daño de grandes y medianas arterias prevalecieron en 66% de los ictus recurrentes; igualmente se evidenció la aterotrombosis como el mecanismo etiopatogénico más prevalerte de los ictus recurrentes. Se registró mayor porciento de recurrencias en las etapas tempranas del seguimiento y tendencia a la recurrencia en aquellos pacientes clasificados como ligeros y moderados en el índice de Katz.

Stroke recurrence is a direct cause of morbility, mortality and discapacity and lingering institucionalitatión among the survivors to a first event stroke. To estimate that factors of risk present bigger value for the recurrent events allows to establish secondary and tertiary, more individualized and efficient measures of prevention. we was carried out a populational analytic and prospective study in surviving patients to a first event ischemic stroke belonging to the area of health of the policlínico "Cristóbal it Works" in the period understood between January of the 2004 and January of the 2006. An effective pursuit was achieved in 289 patients for 24 months. The masculine sex prevailed with 161 cases. The group more affected went the one from 65 to 79 years. They registered a total of 39 cases of recurrent ictus for an accumulated incidence of 0.13. The factors of risk that showed bigger value for the recurrent ictus were the habit of smoking (OR: 1.03, IC 95% 0.60-1.78, p: 0.05) the arterial hypertension (OR: 2.94, IC95%1 .00-8.67, p:0 ,00), the ischemic (OR:1 .95, IC95%:0 .76-3.02, p:0 .03) cardiopatía the hiperlipoproteinemia (OR:2 .28, IC95%1 .46-3.55, p:0 .00), previous ATI, Diabetes Mellitus and the arterial outlying illness. The clinical forms more related with the damage of big and medium arteries they prevailed in 66% of the recurrent ictus, equally it was evidenced the aterotrombosis like the mechanism etiopatogénico more prevalerte of the recurrent ictus. the registered bigger recurrences percent in the early stages of the pursuit and tendency to the recurrencia in those patients classified as slight and moderated in the index of Katz.

Risk Factors Associated with Stroke Recurrence

OBJECTIVE: This study was done to evaluate the risk factors associated with recurrence after first-ever stroke. METHOD: We retrospectively studied 256 first-ever stroke patients treated in Dong-Eui hospital from March 1997 to February 1998. Telephone or out-patient interviews were performed with these patients regarding stroke recurrence and treatment for hypertension and diabetes mellitus. These were divided into two groups, those with recurrence and those without. Evaluated risk factors for stroke recurrence were the following: history of diabetes mellitus, hypertension, heart disease, smoking, alcohol drinking, and transient ischemic attack; clinical findings at admission of hypertension, diabetes mellitus, hyperlipidemia, heart disease, type and location of stroke; treatment compliance for diabetes mellitus and hypertension after discharge. RESULTS: The recurrence rate after first-ever stroke was 12.9%. In univariate analysis, significant risk factors for stroke recurrence were history of smoking, clinical findings at admission of diabetes mellitus, atrial fibrillation, ischemic heart disease, and non-compliance with therapy for diabetes mellitus and hypertension after discharge (p<0.05). In multivariate analysis, significant risk factors for stroke recurrence were atrial fibrillation at admission (odds ratio=3.43) and non-compliance with therapy for hypertension after discharge (odds ratio=7.51)(p<0.05). CONCLUSION: History of smoking, clinical findings at admission of diabetes mellitus, atrial fibrillation, ischemic heart disease, and non-compliance with therapy for diabetes mellitus and hypertension after discharge are considered to be important factors for recurrence of stroke. So treatment and education for those factors associated with stroke recurrence are needed during rehabilitation program.