Using measures of sarcopenia to predict recurrent cerebrovascular events in stroke and TIA patients.

PURPOSE: Sarcopenia is associated with poor outcomes, and evidence suggests an inverse relationship between skeletal muscle mass and cardiovascular risk. Sarcopenia has been studied after stroke, but its value as a risk factor for stroke has not been examined. This prospective cohort study measured sarcopenia in stroke/TIA patients at baseline to explore its role in predicting recurrent events. METHOD: The Arterial Stiffness In lacunar Stroke and TIA (ASIST) study included 96 patients with TIA/lacunar stroke, of which 82 patients (mean age 71.2±10.8 years) had bioimpedance analysis to assess body composition. Skeletal Mass Index (SMI) was calculated and parameters of sarcopenia assessed using Davison (1) and Janssen (2) criteria. Recurrent cerebrovascular events were monitored over 5 years. RESULTS: Eighteen patients had recurrent events. On independent samples t test there were significantly more participants with sarcopenia in the recurrent events group (89% vs 56%, p<0.001) using Davison (1) criteria, as well as lower mean SMI, significantly more participants with diabetes and higher arterial stiffness. On binary logistic regression, the only significant predictors of recurrent events were SMI (p=0.036, hazard ratio=0.414, 95% confidence interval 0.195-0.948) and diabetes (p=0.004, hazard ratio=9.06, 95% confidence interval 2.009-40.860) when corrected for age, sex and cardiovascular risk factors. Using Janssen (2) criteria in the regression, severe sarcopenia was a significant predictor of recurrent events (p=0.028). There was a significant association between sarcopenia and recurrent events on Chi square based on Davison (p=0.02) and Janssen (p=0.034) definitions. CONCLUSIONS: The presence of baseline sarcopenia in stroke and TIA patients is an independent predictor of recurrent events.

White-coat hypertension/effect is associated with higher arterial stiffness and stroke events.

OBJECTIVES: The risk profile of white-coat hypertension/effect (WCH/E) remains unclear. This study aimed to investigate the relationship between WCH/E, markers of cardiovascular risk and cerebrovascular events. METHODS: This is a sub-group analysis of The Arterial Stiffness In lacunar Stroke and Transient ischemic attack (ASIST) study, which recruited 96 patients aged at least 40 years old with a diagnosis of transient ischemic attack or lacunar stroke in the preceding 14 days. Thirty-two patients with target blood pressure (clinic blood pressure <140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) and 30 patients with WCH/E (clinic blood pressure ≥140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) were included in the analysis. RESULTS: Patients with WCH/E were older and had a higher BMI. Central SBP (145 ±â€Š13 vs. 118 ±â€Š8 mmHg, P < 0.001) and DBP (82 ±â€Š8 vs. 76 ±â€Š7 mmHg, P = 0.004) were higher in those with WCH/E. They also had higher arterial stiffness measured by carotid-femoral pulse wave velocity (11.9 ±â€Š3.0 vs. 9.6 ±â€Š2.3 m/s, P = 0.002) and cardio-ankle vascular index (10.3 ±â€Š1.3 vs. 9.4 ±â€Š1.7, P = 0.027). Regression analysis showed an independent relationship between WCH/E and both measures of arterial stiffness. Lacunar strokes were more prevalent in those with WCH/E (47 vs. 22%, P = 0.039) and individuals in this group were more likely to have had a lacunar stroke than a transient ischemic attack (odds ratio 9.6, 95% CI 1.5-62.6, P = 0.02). CONCLUSION: In this cohort of patients with lacunar stroke and transient ischemic attack, WCH/E was associated with elevated markers of cardiovascular risk and a higher prevalence of lacunar stroke. These results suggest that WCH/E is associated with adverse cardiovascular risk.

C-Reactive Protein Predicts Further Ischemic Events in Patients With Transient Ischemic Attack or Lacunar Stroke.

Patients who have experienced a first cerebral ischemic event are at increased risk of recurrent stroke. There is strong evidence that low-level inflammation as measured by high sensitivity C-reactive protein (hs-CRP) is a predictor of further ischemic events. Other mechanisms implicated in the pathogenesis of stroke may play a role in determining the risk of secondary events, including oxidative stress and the adaptive response to it and activation of neuroprotective pathways by hypoxia, for instance through induction of erythropoietin (EPO). This study investigated the association of the levels of CRP, peroxiredoxin 1 (PRDX1, an indicator of the physiological response to oxidative stress) and EPO (a neuroprotective factor produced in response to hypoxia) with the risk of a second ischemic event. Eighty patients with a diagnosis of lacunar stroke or transient ischemic attack (TIA) were included in the study and a blood sample was collected within 14 days from the initial event. Hs-CRP, PRDX1, and EPO were measured by ELISA. Further ischemic events were recorded with a mean follow-up of 42 months (min 24, max 64). Multivariate analysis showed that only CRP was an independent predictor of further events with an observed risk (OR) of 1.14 (P = 0.034, 95% CI 1.01-1.29). No association was observed with the levels of PRDX1 or EPO. A receiver operating curve (ROC) determined a cut-off CRP level of 3.25 µg/ml, with a 46% sensitivity and 81% specificity. Low-level inflammation as detected by hs-CRP is an independent predictor of recurrent cerebrovascular ischemic events.

Balancing immunosuppression and infection: recurrent enterovirus encephalitis in SLE.

A young woman with systemic lupus erythematosus (SLE) developed recurrent enterovirus meningoencephalitis while taking prednisolone, azathioprine and rituximab. After reducing the immunosuppression, she developed a central nervous system (CNS) flare of SLE, with enterovirus still present in the cerebrospinal fluid (CSF). There are no evidence-based specific treatments for enterovirus encephalitis, but she responded well to intravenous immunoglobulin alongside pulsed methylprednisolone and rituximab. This case highlights the difficulties in managing people with co-existing infective and autoimmune conditions, especially if each affects the CNS. A viral infection and SLE flare can resemble one another clinically, although here the radiological differentiation of CNS lupus versus enterovirus encephalitis helped to guide the diagnosis.

Independent Association Between Cardio-Ankle Vascular Index and Sarcopenia in Older U.K. Adults.

OBJECTIVES: To investigate the correlation between sarcopenia and arterial stiffness in Caucasians, centering on the relationship between skeletal mass index (SMI) and the cardio-ankle vascular index (CAVI) to assess the use of CAVI in predicting sarcopenia. DESIGN CROSS-SECTIONAL SETTING: United Kingdom. PARTICIPANTS: UK adults aged 45 years and over (N = 366, n = 177 male, n = 189 female). MEASUREMENTS: Bioimpedance analysis was used to derive SMI. CAVI score was calculated using a vascular screening system. Handgrip strength was measured using a standard dynamometer. RESULTS: Average CAVI was significantly correlated with SMI (correlation coefficient (r) = -0.285, p < .001), with higher correlation in women (r = -0.416, p < .001) than men (r = -0.214, p = .01). CAVI had the highest correlation with SMI from appendicular muscle (fat-free mass in men, r = -0.253, p = .002; predicted muscle mass in women, r = -0.436, p < .001). There was a significant difference in average CAVI between groups, with participants who were not sarcopenic having lower CAVI (8.98) than those who were sarcopenic (9.80) (p < .001, t-test). Linear regression was performed using SMI as the dependent variable. After adjustment for age, average CAVI was a significant predictor of SMI in women (beta = -0.332, p < .001) but not men. CONCLUSION: Indices of sarcopenia are independently associated with a higher CAVI, with greater correlation in women than men. The CAVI can be used to assess overall vascular compliance and may be a useful operator-independent tool that can be used to measure sarcopenia and its cardiovascular implications in older adults. J Am Geriatr Soc 67:317-322, 2019.