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Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital
High Systolic Blood Pressure upon Stroke Admission Associated with Higher Mortality
Source: Geeganage C, Tracy M, England T, et al. Relationship between baseline blood pressure parameters (including mean pressure, pulse pressure, and variability) and early outcome after stroke. Data from the Tinzaparin in Acute Iscaemic Stroke Trial (TAIST). Stroke 2011;42:491-493.
Controversy remains regarding the optimal blood pressure early in the course of ischemic stroke. The investigators looked back at the TAIST trial admission blood pressure data on 1,479 patients to determine if there were hemodynamic variables that had an impact on subsequent morbidity and mortality. Baseline systolic BP, mean BP, heart rate, pulse pressure (PP), and systolic BP variability were correlated with the following outcomesdeath, neurologic deterioration, death or deterioration, and stroke recurrence. Binary logistic regression with adjustment for baseline prognostic factors, time to treatment, and treatment assignment were performed.
a. day 10, death or neurologic deterioration was associated with systolic BP (adjusted odds ratio [OR] = 1.02; 95% confidence interval [CI], 1.01-1.03), mean arterial pressure (OR = 1.02; 95% CI, 1.01-1.04), pulse pressure (OR = 1.02; 95% CI, 1.01-1.03), and BP variability (OR = 1.03; 95% CI, 1.01-1.05). The data suggest that these hemodynamic parameters may be potential therapeutic targets to improve outcome after ischemic stroke.
Should Statins Be Avoided After Intracerebral Hemorrhage?
Source: Westover MB, Bianchi MT, Eckman MH, Greenberg SM. Statin use following intracerebral hemorrhage. A decision analysis. Arch Neurol 2011. doi:10.1001/archneurol.2010.356.
Statins are used widely for both primary and secondary prevention of ischemic cardiovascular disease and stroke. Recent studies have suggested that there may be an increased risk of intracerebral hemorrhage (ICH) with very low levels of LDL as well as the use of high doses of a statin. In order to assess the possible hazard of using a statin in patients who have already sustained an ICH, the authors created a simulated clinical trials model (Markov model), using a computer program that calculates the risk of recurrent ICH, based on the location of the hematoma (deep or lobar) and the presence of other risk factors, such as hypertension and dementia. The main outcome measure was life expectancy, measured as quality-adjusted life-years (QALYs).
a.ter ICH, the avoidance of statins was favored in this computer model, particularly in survivors of lobar ICH who are at the highest risk for recurrent ICH. Survivors of ICH, who have no other cardiovascular events, gain 2.2 QALYs if they avoid statins. In patients who had a lobar ICH and prior cardiovascular events, the annual risk of heart attack would have to exceed 90% to favor statin therapy. Even survivors of deep ICH appear to have a survival benefit by avoiding statins. Because this study is based on a computer model, a real-life cohort study or case-control study is needed before any treatment recommendations can be made regarding statins.
Patients with Ischemic Strokes Have Lower Mortality if Treated at a Certified Stroke Center
Source: Xian Y, Holloway RG, Chan PS, et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA 2011;305:373-380.
The joint commission began certification of stroke centers, based on the Brain Attack Coalition (BAC) recommendations, in 2003. New York, Massachusetts, and Florida have developed their own designation program also using the BAC criteria. However, data collection and monitoring of these programs all have been based on process measures, such as "door-to-CT scan" time and use of thrombolytics. In order to assess the impact of stroke centers on mortality, the investigators reviewed hospital data from the New York Statewide Planning and Research Cooperative System (SPARCS) for 33,090 adult patients with a principal diagnosis of acute ischemic stroke between January 1, 2005 and December 31, 2006. By the end of 2006, 104 (42.6%) of 244 New York hospitals became state-designated stroke centers, and these hospitals were compared to non-designated hospitals.
a. the primary outcome measure, the investigators examined 30-day all-cause mortality, and secondary outcome measures were 1-day, 7-day, and 1-year all-cause mortality. Among 30,947 acute ischemic stroke patients, 15,297 (49.4%) were admitted to designated stroke centers, and this selective admission was associated with a lower 30-day all-cause mortality (10.1% vs. 12.5%; P < 0.001), and greater use of thrombolytic therapy (4.8% vs. 1.7%; P < 0.001). Differences in mortality were observed at 1-day, 7-day, and 1-year follow-up, and these differences were specific for stroke, as there were no differences in mortality between center-type for patients with other diagnoses, including GI hemorrhage or acute myocardial infarction. Among patients with acute ischemic stroke, admission to a designated stroke center was associated with lower mortality.