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Predicting Stroke Risk in Patients With ACS

Predicting Stroke Risk in Patients With ACS

Clinical outcomes after stroke can be devastating and include high risks of mortality and severe debilitation. In a study published in the American Journal of Cardiology, my colleagues and I sought to develop a clinical risk prediction model that would allow physicians to identify patients with acute coronary syndrome (ACS) who are at a higher risk of developing in-hospital stroke. We wanted to identify independent risk factors for developing a stroke in the acute time period of an ACS. The final model was created based on data from 63,118 patients with a total of 217 ischemic strokes. Testing a New Model Using a multivariable analysis, eight baseline and presenting clinical characteristics were independently associated with the occurrence of ischemic stroke: 1. Older age. 2. Atrial fibrillation or flutter on index electrocardiogram. 3. Systolic blood pressure ≥160 mm Hg. 4. Positive initial cardiac biomarkers. 5. No previous or current smoking. 6. ST segment change. 7. Killip class II to IV. 8. Lower body weight. The risk prediction model for the primary endpoint of ischemic stroke within 14 days of hospitalization was developed by converting final model estimates to points. For example, each 10-kg decrease in weight, starting with 210 kg to 219 kg, was assigned 1 point. Atrial fibrillation or flutter was assigned 4 points. Points for each of any of the eight patient factors were summed to obtain a total patient risk score. Patients with risk scores of 21 to 27 had a 14-day stroke risk of about 0.4%. This risk increased to more than 1.0% when scores rose above 30 points and to 1.0% or 2.0% in those...
Early Management of Acute Ischemic Stroke

Early Management of Acute Ischemic Stroke

In 2013, the American Heart Association (AHA) and American Stroke Association (ASA) updated guidelines on the early management of acute ischemic stroke, representing the first update to these recommendations since 2007. Several substantial changes were incorporated into the new guidelines. The new document incorporates an AHA/ASA science advisory from 2009 that recommends the use of tissue plasminogen activator in appropriate patients who present to hospitals within 3.0 to 4.5 hours of symptom onset. It’s also recommended that door-to-needle times be less than 60 minutes for patients who are eligible for thrombolysis. The FDA approvals of the Trevo Retriever (Concentric Medical) system and Solitaire Flow Restoration (Covidien) device were significant new advances that were addressed in the guideline update. These devices are alternatives to coil retrievers and offer clinicians a new mechanical approach for restoring blood flow to occluded arteries. The updated AHA/ASA guidelines recommend that the Trevo Retriever system and Solitaire Flow Restoration device be the preferential choice when mechanical thrombectomy is pursued. Since 2007, several studies have focused on the use of decompressive surgery for malignant cerebral edema. These new data led to the recommendation that this approach be considered for acute ischemic stroke patients with large infarcts because of its potential life-saving capabilities and because it can restore a reasonable quality of life in appropriately selected patients. Implications for Emergency Medicine & Stroke Emergency physicians and nurses should be intimately integrated into the care of stroke patients. The AHA/ASA guideline recognizes that the saying “time is brain” is more critical than ever before. Timely, definitive care must be delivered in the ED. Emergency physicians need to be...

Stroke Risk in Hip Replacement Patients

Patients undergoing total hip replacement (THR) have 4.7-fold and 4.4-fold increased risks of ischemic stroke and hemorrhagic stroke, respectively, during their first 2 postoperative weeks, according to a Danish study. The authors added that outpatient antiplatelet drug use lowered 6-week hazard ratios for ischemic stroke by 70% in THR patients, but the risk of hemorrhagic stroke was unaffected by use of these medications. Abstract: Stroke, December...

Conference Highlights: ASE 2012

New research was presented at ASE 2012, the American Society of Echocardiography’s 23rd Annual Scientific Sessions, from June 30 to July 3 in Maryland. The features below highlight just some of the studies that emerged from the conference. Echocardiograms for Diagnosing Pulmonary Hypertension The Particulars: Patients with stable heart failure who have high pulmonary artery systolic pressure are at increased risk for adverse outcomes. A reliable method is needed for measuring pulmonary artery systolic pressure in this patient population. Data Breakdown: Emory University researchers used echocardiography to diagnose pulmonary hypertension— defined as pulmonary artery systolic pressure higher than 45 mm Hg—in stable outpatients with heart failure. Echocardiography was found to strongly predict higher risk of clinical events. The testing also helped determine which patients would have higher hospitalization rates. Take Home Pearl: Pulmonary artery systolic pressure as measured by echocardiography appears to provide important prognostic information for patients with stable heart failure. Ultrasonography Helps Predict Atherosclerosis The Particulars: The incidence of peripheral arterial disease is rising throughout the United States. However, data from large population-based samples on the prevalence of subclinical atherosclerosis in the peripheral arteries are lacking. Data Breakdown: Investigators in a study used ultrasound exams to look for the presence and degree of popliteal arterial plaque as a predictor of atherosclerosis. Popliteal artery atherosclerosis was prevalent among patients aged 40 or younger who were at risk for becoming obese and/ or having diabetes. Popliteal artery atherosclerosis was independently associated with older age and albuminuria. Urinary albuminuria was also linked with the severity of atherosclerotic plaque burden in the popliteal arteries. Take Home Pearl: Among younger patients with...

Hyperlactatemia & Ischemic Stroke

In patients with ischemic stroke, initial hyperlactatemia appears to be an independent risk factor for poor outcomes, according to South Korean investigators. In a retrospective analysis involving 292 patients with ischemic stroke, 183 individuals (62.7%) were considered to have poor outcomes and 16 (5.5%) died. Seventy (24.0%) of the study participants had initial hyperlactatemia. In multivariable logistic regression analyses, hyperlactatemia was associated with a 2.15-times greater risk of poor outcome at 3 months and a 4.31-times greater risk of death when compared with those without hyperlactatemia. Abstract: American Journal of Emergency Medicine, March...
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