Acute Ischemic Stroke and Heart Failure: Stroke Risk Factors Associated with Exclusion from Thrombolytic Therapy.

Objective: Acute ischemic stroke (AIS) patients with congestive heart failure (HF) that present with various risk factors are less likely to receive recombinant tissue plasminogen activator (rtPA). The risk factors associated with excluding AIS patients with congestive heart failure (AIS-HF) from rtPA therapy have not been fully established. Methods: Retrospective data for 5469 AIS patients comprised of 590 AIS patients with HF and 4879 AIS patients without HF were collected from a regional stroke registry between January 2010 and June 2016. Baseline risk factors were analyzed using logistic regression analysis to determine the risk factors associated with rtPA exclusion in AIS-HF patients. Results: In the adjusted analysis, AIS-HF patients that that did not receive rtPA were more likely to be older (OR = 0.982, 95% CI, 0.966-1, P = .020), presented with coronary artery disease (OR = 0.618, 95% CI, 0.391-0.98, P = .040), and with an elevated INR (OR = 0.326, 95% CI, 0.129-0.82, P = .018). AIS-HF patients that were included for rtPA therapy were more likely to show improvement in ambulatory status (OR = 1.69, 95% CI, 1.058-2.7, P = .028). The discriminating power of the model was strong with an area under the curve (AUROC) = 0.668 (95% CI, 0.611-0.724, P < .001). Conclusion: Our study establishes the associations between stroke risk factors and exclusion from rtPA therapy. This finding suggests the need to develop management strategies for older HF patients with carotid artery disease and an elevated INR to improve their eligibility for rtPA treatment following an acute ischemic stroke.

Analysis of severity in ischemic stroke patients with coronary artery disease in the telestroke network.

Aim: This study investigated demographic and clinical risk factors associated with severity in acute ischemic stroke (AIS) patients with a history of coronary artery disease (CAD). Materials & methods: Multivariate logistic regression models were used to determine specific factors associated with worsening or improving neurologic functions among AIS patients with CAD treated in the telestroke. Results: AIS patients with CAD, peripheral vascular disease (OR: 3.995; 95% CI: 1.035-15.413; p = 0.044) and hypertension (OR: 6.056; 95% CI: 1.207-30.374; p = 0.029) were associated with worsening neurologic functions. Conclusion: Our findings suggest the need to develop strategic management to improve the care of AIS patients with a history of CAD that present with hypertension and peripheral vascular disease in the telestroke network.

This study investigated risk factors that contribute to poor outcomes in stroke patients with a history of coronary artery disease. We used advanced statistical approach to identify risk that contribute to poor neurologic functions. We observed that peripheral vascular disease and hypertension were associated with worsening neurologic functions. Our findings suggest the need to develop management plans to improve the care of acute ischemic stroke patients with a history of coronary artery disease that present with hypertension and peripheral vascular disease in the telestroke network.

Stroke Severity among Men and Women Acute Ischemic Stroke Patients in the Telestroke Network.

INTRODUCTION: This study investigates gender differences among stroke patients treated in the telestroke network using specific risk factors that contribute to stroke severity. METHODS: We examined gender differences in stroke severity among 454 patients hospitalized with acute ischemic stroke (AIS). The logistic regression model was used to predict clinical risk factors associated with stroke severity in men and women AIS patients. RESULTS: In the adjusted analysis among women patients, increasing age (odds ratio [OR] = 1.05, 95% CI: 1.017-1.085, p = 0.003) and higher heart rate (OR = 1.031, 95% CI: 1.005-1.058, p = 0.021) were associated with worsening neurological functions, while direct admission (OR = 0.191, 95% CI: 0.079-0.465, p < 0.001) was associated with improving neurologic functions. Among men, hypertension (OR = 3.077, 95% CI: 1.060-8.931, p = 0.039) and higher international normalized ratio (INR) (OR = 21.959, 95% CI: 1.489-323.912, p = 0.024) were associated with worsening neurologic functions, while Caucasian (OR = 0.181, 95% CI: 0.062-0.526, p = 0.002) and obesity (OR = 0.449, 95% CI: 0.203-0.99, p = 0.047) were associated with neurologic improvement. CONCLUSION: Increasing age and heart rate in women, hypertension and greater INR in men contribute to worsening neurologic functions. There is a need to develop strategies to improve the care of both men and women in the telestroke network.

Retrospective analysis of comorbidities in stroke patients with a history of obstructive sleep apnea treated with thrombolytic therapy.

BACKGROUND: The eligibility criteria for thrombolytic therapy may differ between acute ischemic stroke patients (AIS) patients with and without incidence of obstructive sleep apnea (OSA). In this study, we determine the effect of specific comorbidities in the exclusion and inclusion for recombinant tissue plasminogen activator (rtPA) administration in the AIS population with OSA. METHODS: Retrospective data from a stroke registry were analyzed for baseline clinical and demographic factors in AIS patients with OSA for rtPA therapy from January 2010 to June 2016. The logistic regression model was developed to identify each of the variables predicting inclusion for or exclusion from rtPA. We estimated the odds of the inclusion or exclusion of a particular demographic and clinical risk factor in AIS with and without OSA for rtPA therapy. The validity of the model was tested using a Hosmer-Lemeshow test and the sensitivity of the model was determined using a Receiver Operating Curve (ROC). RESULTS: A total of 170 AIS patients with OSA were identified, of which, 125 did not receive rtPA while 45 received rtPA. Adjusted analysis showed that in the AIS population with OSA, administration of rtPA was associated with a history of dyslipidemia (OR=3.192, 95% CI, 1.148-8.88, p=0.026), direct admission into a Comprehensive Stroke Center (OR=3.248, 95% CI, 1.06-9.95, p=0.039), and ambulatory improvement (OR=3.556, 95% CI, 1.428-8.86, p=0.006). There were no significant factors associated with rtPA exclusion in the AIS population with OSA. CONCLUSION: The prevalence of OSA in our AIS population was low and no clinical risk factor was associated with the exclusion of patients with AIS and OSA from thrombolytic therapy. Future studies are necessary to explore the effect of OSA in AIS patients to improve eligibility for rtPA therapy for more patients.

Gender disparity in a cohort of stroke patients with incidence of obstructive sleep apnea.

BACKGROUND: Differences in baseline clinical risk factors have been proposed to contribute to gender differences in stroke outcome, how these clinical risk factors contribute to gender difference in acute ischemic stroke (AIS) patients with obstructive sleep apnea is yet to be fully investigated. This study explored the clinical characteristics associated with gender differences in AIS population with a baseline obstructive sleep apnea(OSA). METHODS: A retrospective study was conducted using data from 5469 patients with an ischemic stroke event from a regional stroke center collected from January 2010 to June 2016. Multivariate logistic regression was used to determine factors associated with gender differences in the obstructive sleep apnea-ischemic stroke population. RESULTS: A total of 170 AIS patients presented with a baseline OSA, and 101 were men and 69 were women. In the AIS with OSA (AIS-OSA) population, patients presenting with peripheral vascular disease (PVD) (OR = 4.892, 95% CI,1.248 - 19.2, P = 0.023), depression (OR = 3.804, 95% CI, 1.369 - 10.6, P = 0.01), higher BMI (OR = 1.103, 95% CI, 1.036 - 1.18, P = 0.002), and higher HDL levels (OR = 1.125, 95% CI, 1.067 - 1.19, P = < 0.001) were associated with increasing odds of being women, and no clinical risk factor was associated with men AIS-OSA patients. CONCLUSION: A gender specific difference was observed in pre-stroke demographic and risk factors for AIS patients with OSA. Women AIS patients with OSA were more likely to present with PVD and depression and have higher HDL and BMI levels when compared to men within the same population. In addition, more men AIS presented with OSA when compared with women AIS patients. Further studies to explore management strategies to eliminate gender differences will improve outcomes for men and women AIS with OSA.

Age Stratification in Acute Ischemic Stroke Patients with Heart Failure.

Background and Purpose. Heart failure (HF) is considered one of the major risk factors associated with the severity of acute ischemic stroke(AIS). The risk factors associated with stroke severity in AIS with a history of HF is not fully understood. Methods. A prospectively maintained database from comprehensive stroke centers in PRISMA Health Upstate Sc, was analyzed for patients with AIS and a history of HF from January 2010 to 30 June 2016. The primary outcome was risk factors associated with a National Institute of Health Stroke Scale score (NIHSS) < 7 indicating lower severity and a score ≥ 7 indicating high severity for 65−74 age category and ≥75 years age category for AIS-HF patients. Univariate analysis was used to determine risk factors based on age categories and stroke severities, while multivariable analysis was used to adjust for the effect of confounding variables. Results: A total 367 AIS-HF patients were identified in this study, 113 patients were between 65−74 years old, while 254 patients were in the ≥75 years old age category. In the adjusted analysis for 65−74 age category, history of smoking (OR = 0.105, 95% Confidence interval (CI): 0.018−0.614, p = 0.012), triglycerides (Odd ratio(OR) = 0.993, 95% (CI): 0.987−0.999, p = 0.019), and International Normalized Ratio (INR) (OR = 0.454, 95% CI: 0.196−1.050, p = 0.045), and direct admission treatment (OR = 0.355, 95% CI: 0.137−0.920, p = 0.033) were associated with a lower stroke severity, elevated heart rate (OR = 1.032, 95% CI: 1.009−1.057, p = 0.007) was associated with a higher stroke severity. For the ≥75 years old age category, previous stroke (OR = 2.297, 95% CI: 1.171−9.852, p = 0.024), peripheral vascular disease (OR = 6.784, 95% CI: 1.242−37.065, p = 0.027), heart rate (OR = 1.035, 95% CI: 1.008−1.063, p = 0.012), and systolic blood pressure (OR = 1.023, 95% CI: 1.005−1.041, p = 0.012) were associated with a higher severe stroke severity. Conclusions: After adjusting for the effect of potential confounders, more risk factors were associated with a high severity of stroke among ≥75 years old compared with 65−74 years old AIS-HF patients. Elevated heart rate was an independent risk factor associated with stroke severity in 65−74 and ≥75 years old AIS-HF patients. Elevated heart rate and other identified risk factors should be managed to reduce stroke severity among elderly AIS-HF patients.

Obstructive sleep apnea and stroke severity: Impact of clinical risk factors.

BACKGROUND: Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA. METHODS: This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer-Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve. RESULTS: A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289-8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123-7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06-0.767, P = 0.018) was associated with NIHSS score ≤7. CONCLUSION: In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

Gender differences in comorbidities and risk factors in ischemic stroke patients with a history of atrial fibrillation.

BACKGROUND: Atrial Fibrillation (AF) is a common cardiac arrhythmia and has been identified as a major risk factor for acute ischemic stroke (AIS). Gender differences in the disease process, causative mechanisms and outcomes of AF have been investigated. In the current study, we determined whether there is a gender-based disparity in AIS patients with baseline AF, and whether such a discrepancy is associated with specific risk factors and comorbidities. METHODS: Baseline factors including comorbidities, risk and demographic factors associated with a gender difference were examined using retrospective data collected from a registry from January 2010 to June 2016 in a regional stroke center. Univariate analysis was used to differentiate between genders in terms of clinical risk factors and demographics. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor were used to predict the increasing odds of an association of a specific comorbidity and risk factor with the male or female AIS with AF. RESULTS: In the population of AIS patients with AF, a history of drug and alcohol use (OR = 0.250, 95% CI, 0.497-1.006, P = 0.016), sleep apnea (OR = 0.321, 95% CI, 0.133-0.777, P = 0.012), and higher serum creatinine (OR = 0.693, 95% CI, 0.542-0.886 P = 0.003) levels were found to be significantly associated with the male gender. Higher levels of HDL-cholesterol (OR = 1.035, 95% CI, 1.020-1.050, P < 0.001), LDL-cholesterol (OR = 1.006, 95% CI, 1.001-1.011, P = 0.012), and the inability to ambulate on admission to hospital (OR = 2.258, 95% CI, 1.368-3.727, P = 0.001) were associated with females. CONCLUSION: Our findings reveal that in the AIS patients with atrial fibrillation, migraines, HDL, LDL and poor ambulation were associated with females, while drugs and alcohol, sleep apnea, and serum creatinine level were associated with male AIS patients with AF. Further studies are necessary to determine whether gender differences in risk factor profiles and commodities require consideration in clinical practice when it comes to AF as a risk factor management in AIS patients.

Role of dyslipidemia in ischemic stroke patients treated in the telestroke network.

PURPOSE: The relationship between the telestroke technology and clinical risk factors in a dysplipidemic ischemic stroke population and neurologic outcomes is not fully understood. This issue was investigated in this study. PATIENTS AND METHODS: We analyzed retrospective data collected from a regional stroke registry to identify demographic and clinical risk factors in patients with improving (NIHSS â€‹≤ â€‹7) or worsening (NIHSS â€‹> â€‹7) neurologic outcome in dyslipidemic ischemic stroke population. We used logistic multivariate models to identify independent predictors of improving or worsening outcome based on dyslipidemia disease status in ischemic stroke patients. RESULTS: In the adjusted analysis for dyslipidemic ischemic stroke population, cholesterol reducer use (odd ratio; [OR] â€‹= â€‹0.393, 95% confidence interval [CI], 0.176-0.879, P â€‹= â€‹0.023) and direct admission (OR â€‹= â€‹0.435, 95% CI, 0.199-0.953, P â€‹= â€‹0.037) were more likely to be associated with neurologic improvement and no clinical or demographic factors were associated with poor neurologic outcome in dyslipidemic ischemic stroke patients treated in the telestroke network. For the ischemic stroke population without dyslipidemia, increasing age (OR â€‹= â€‹1.070, 95% CI, 1.031-1.109, P â€‹< â€‹0.001), coronary artery disease (OR â€‹= â€‹3.633, 95% CI, 1.307-10.099, P â€‹= â€‹0.013), history of drug or alcohol abuse (OR â€‹= â€‹6.548, 95% CI, 1.106-38.777, P â€‹= â€‹0.038), and improvement in ambulatory outcome (OR â€‹= â€‹2.880, 95% CI, 1.183-7.010, P â€‹= â€‹0.020) were associated with worsening neurological functions, while being Caucasian (OR â€‹= â€‹0.294, 95% CI, 0.098-0.882, P â€‹= â€‹0.029) was associated with improving neurologic functions. CONCLUSION: Demographic and clinical risk factors among the dysplipidemic ischemic stroke population in the telestroke network were not associated with worsening neurologic functions.