Ahmed Malik

Incident Cancer in a Cohort of 3,247 Cancer Diagnosis Free Ischemic Stroke Patients

Background: Subclinical cancer can manifest as a thromboembolic event and may be detected at a later interval in ischemic stroke survivors. We determined the rate of incident cancer and effect on cardiovascular endpoints in a large cohort of ischemic stroke survivors. Methods: An analysis of 3,680 adults with nondisabling cerebral infarction who were followed for two years within the randomized, double-blinded VISP trial was performed. The primary intervention was best medical/surgical management plus a daily supplementation of vitamin B6, vitamin B12, and folic acid. We calculated age-adjusted rates of incidence of cancer among ischemic stroke survivors and standardized incidence ratios (SIR) with 95% confidence intervals (CI) based on comparison with age-adjusted rates in the general population. The significant variables from univariate analysis were entered in a Cox Proportional Hazards analysis to identify the association between various baseline factors and incident cancer after adjusting age, gender, and race/ethnicity. A logistic regression analysis evaluated the association between incident cancer and various endpoints including stroke, coronary heart disease, myocardial infarction, and death after adjusting age, gender, and race/ethnicity. Results: A total of 3,247 patients (mean age ± SD of 66 ± 11; 2,013 were men) were cancer free at the time of enrollment. The incidence of new cancer was 0.15, 0.80, 1.2, and 2.0 per 100 patients at 1 month, 6 months, 1 year, and 2 years, respectively. The age-adjusted annual rate of cancer in patients with ischemic stroke was higher than in persons in the general population at 1 year (581.8/100,000 persons vs. 486.5/100,000 persons, SIR 1.2, 95% CI 1.16-1.24) and 2 years (1,301.7/100,000 vs. 911.5/100,000, SIR 1.4, 95% CI 1.2-1.6) after recruitment. There was a higher risk for death (odds ratio (OR) 3.1, 95% CI 1.8-5.4), and composite endpoint of stroke, coronary heart disease, and/or death (OR 1.4, 95% CI 1.0-2.2) among participants who developed incident cancer compared with those who were cancer free after adjusting for potential confounders. Conclusions: The annual rate of age-adjusted cancer incidence was higher among ischemic stroke patients compared with those in the general population. The odds of mortality were three folds higher among stroke survivors who developed incident cancer.

Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States.

BACKGROUND CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) results, published in 2010, showed no difference in the rates of composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). OBJECTIVE To identify any changes in use and outcomes of CAS and CEA subsequent to the CREST results. METHODS We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National Inpatient Sample (NIS). Demographic and clinical characteristics and in-hospital outcomes of pre- and post-CREST CAS-treated and post-CREST CEA-treated patients were compared with pre-CREST CEA-treated patients. RESULTS A total of 225,191 patients underwent CEA or CAS in the pre- and post-CREST periods. The frequency of CAS among carotid revascularization procedures did not change after publication of the CREST results (12.3% vs. 12.7%, P = .9). In the pre-CREST period, the CAS group (compared with the CEA group) had higher rates of congestive heart failure (P < .001), coronary artery disease (P < .001), and renal failure (P < .001). The post-CREST CAS group had a higher frequency of atrial fibrillation (P = .003), congestive heart failure (P < .0001), coronary artery disease (P < .0001), and renal failure (P = .0001). Discharge with moderate to severe disability (P < .0001) and postprocedure neurological complications (P = .005) were more frequently reported in the post-CREST CAS group. After adjusting for age, sex, and risk factors, the odds ratio (OR) for moderate to severe disability was 1.0 (95% confidence interval [CI]: 0.8-1.2) in the pre-CREST CAS group and 1.4 (95% CI: 1.1-1.7) in the post-CREST CAS group compared with the reference group. The adjusted OR for neurological complications in the pre-CREST CAS group was 1.6 (95% CI: 1.2-2.1, P = .002), and 1.5 (95% CI: 1.1-2.0, P = .01) in the post-CREST CAS group. CONCLUSION The frequency of CAS and CEA for carotid artery stenosis has not changed after publication of the CREST. The demographics, pretreatment comorbidity profile, and in-hospital complication rates remained unchanged during the 2 time periods.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Maintenance Dialysis Patients

Outcomes of cardiopulmonary resuscitation (CPR) in hospitalized patients with ESRD requiring maintenance dialysis are unknown. Outcomes of in-hospital CPR in these patients were compared with outcomes in the general population using data from the Nationwide Inpatient Sample (NIS; 2005-2011). The study population included all adults (≥ 18 years old) from the general population and those with a history of ESRD. Baseline characteristics, in-hospital complications, and discharge outcomes were compared between the two groups. The effects of in-hospital CPR on mortality, length of stay, hospitalization charges, and discharge destination were analyzed. Yearly national trends in survival, discharge to home, and length of stay were also examined using the Cochran-Armitage trend test. During the study period, 56,069 patients with ESRD underwent in-hospital CPR compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with ESRD (73.9% versus 71.8%, P<0.001) on univariate analysis. After adjusting for age, gender, and potential confounders, patients with ESRD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.3; P<0.001). Survival after CPR improved in the year 2011 compared with 2005 (31% versus 21%, P<0.001). Multivariate analysis also revealed that a greater proportion of patients with ESRD who survived were discharged to skilled nursing facilities. In conclusion, outcomes after in-hospital CPR are improving in patients with ESRD but remain worse than outcomes in the general population. Patients with ESRD who survive are more likely to be discharged to nursing homes.

Pregnancy in advanced age and the risk of stroke in postmenopausal women: analysis of Women’s Health Initiative Study

BACKGROUND: The incidence of pregnancy in advanced age among women is increasing because of the availability of assisted reproduction, although the long‐term health consequences are not known. OBJECTIVE: The purpose of this study was to determine the effect of pregnancy in advanced age on the occurrence of cardiovascular events in a large cohort of postmenopausal women. STUDY DESIGN: We analyzed the data for 72,221 women aged 50‐79 years who were enrolled in the observational arm of the Women’s Health Initiative study. We determined the effect of pregnancy in advanced age (last pregnancy at age ≥40 year) on the risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and cardiovascular death over a mean period (±standard deviation) of 12±1 years using Cox Proportional Hazards analysis after adjusting for potential confounders. RESULTS: A total of 3306 of the 72,221 participants (4.6%) reported pregnancy in advanced age. Compared with pregnancy in normal age, the rates of ischemic stroke (3.8% vs 2.4%), hemorrhagic stroke (1.0% vs 0.5%), and cardiovascular death (3.9% vs 2.3%) were significantly higher among women with pregnancy in advanced age. In multivariate analysis, women with pregnancy in advanced age were 50% more likely to experience a hemorrhagic stroke (hazard ratio, 1.5; 95% confidence interval, 1.0–2.1) after adjustment for age, race/ethnicity, congestive heart failure, systolic blood pressure, atrial fibrillation, alcohol use, and cigarette smoking. There was no significant difference in the risk of ischemic stroke, myocardial infarction, and cardiovascular death among women with pregnancy in advanced age after adjustment for potential confounders. CONCLUSION: Women with pregnancy at an advanced age have a higher risk for hemorrhagic stroke in the postmenopausal period.

Readministration of intravenous alteplase in acute ischemic stroke patients: case series and systematic review

BACKGROUND Because of a high risk of recurrence of ischemic events, some patients may be candidates for readministration of intravenous (IV) alteplase. METHODS We performed a single-center review and performed a search on PubMed from January 1966 to April 2014 for cases of readministration of alteplase. Favorable outcome was defined by a modified Rankin scale of 0 to 2 at discharge or at 1 to 3 months, improvement of greater than or equal to 4 points within 24 hours in the National Institutes of Health Stroke Scale score, or as a major improvement in the 72-hour National Institutes of Health Stroke Scale score. RESULTS Four ischemic stroke patients underwent readministration of IV alteplase in our single-center review. None of the patients had symptomatic or asymptomatic intracerebral hemorrhage.In 2 patients, IV alteplase had been administered for a previous acute ischemic stroke, 6 and 49 days before the index ischemic stroke.At discharge, both patients had a favorable outcome. A total of 22 cases of readministration of alteplase for ischemic stroke have been reported in literature. The mean interval between the 2 administrations of alteplase was 428 days (range, 3 hours to 2280 days).Asymptomatic post thrombolytic intracerebral hemorrhages were seen in 2 patients. Favorable outcome was seen in 16 patients. A total of 9 underwent readministration of IV alteplase within 3 months for recurrent ischemic stroke. Favorable outcome was seen in 5 of these 9 patients. CONCLUSIONS We observed a relatively high rate of favorable outcomes and a small rate of adverse events after readministration of IV alteplase in ischemic stroke patients.

Worse in-hospital outcomes in patients with transient ischemic attack in association with acute kidney injury: analysis of nationwide in-patient sample.

Objectives: The effect of acute kidney injury (AKI) on outcomes of transient ischemic attack (TIA) is largely unknown. We wanted to determine the impact of AKI on the outcomes of patients admitted with TIA. Methods: Data from all adult patients admitted to the U.S. hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of AKI were included, using the nationwide in-patient dataset. The association of AKI with TIA-related mortality and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Results: Of the 1,173,340 patients admitted with TIA, 45,974 (3.8%) had AKI. Dialysis was required in 29 (0.06%) patients. TIA patients with AKI had higher rates of moderate-to-severe disability (21.2 vs. 13.7%, p ≤ 0.0001), and in-hospital mortality (0.6 vs. 0.1%, p ≤ 0.0001) compared with those without AKI. After adjusting for age, sex, and potential confounders; TIA patients with AKI had higher odds of moderate-to-severe disability [OR 1.3, 95% CI 1.2-1.4, p < 0.0001] and death (OR 4.2, 95% CI 3.0-6.1, p < 0.0001). Conclusions: AKI in patients with TIA is associated with significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality compared with those without AKI.

Oral contraceptive use and incident stroke in women with sickle cell disease

OBJECTIVE Oral contraceptives increase the risk of ischemic stroke among women. However, the effect is not studied in the stroke prone sickle cell disease (SCD) population. We want to determine the rate of incident stroke among women with SCD enrolled in a large cohort with longitudinal follow-up. STUDY DESIGN A total of 1257 women aged ≥15 and <45years, enrolled in Phase 1 of Cooperative Study of SCD, underwent a baseline examination for assessment of demographics, prior medical history, laboratory assessments, and clinical data. The effects of active oral contraceptive use at baseline interview on incident ischemic and hemorrhagic strokes were assessed after adjusting for potential confounders using Cox Proportional Hazards analysis. RESULTS A total of 178 (14.2%) of 1257 women with SCD reported use of oral contraceptives. The age adjusted annual incidence of incident stroke was four folds higher among women who reported active oral contraceptive use than those who did not report use (1.6/100 person-years versus 0.4/ 100 person-years, p=0.03). After adjusting for age, cigarette smoking status, history of exchange transfusions, alcohol use, body weight, systolic blood pressure, and heart rate, oral contraceptive use was not significantly associated with rate of ischemic stroke (hazards ratio [HR], 3.6 95% confidence interval [CI] 0.8-16.5, p=0.09) or hemorrhagic stroke (HR, 1.2 95% CI 0.2-5.7, p=0.8). CONCLUSIONS The four fold higher risk of incident stroke associated with use of oral contraceptives in women with SCD can be mitigated by controlling other cardiovascular risk factors. IMPLICATIONS Our results are expected to increase the awareness, among both medical practitioners and patients, regarding the four fold higher risk of incident stroke associated with use of oral contraceptives in women with SCD. Our results also identify the confounding effect of other cardiovascular risk factors such as cigarette smoking on the observed relationship and thus identify potential targets for prevention.

Factors Associated With Increased In-Hospital Mortality Among Children With Intracerebral Hemorrhage

We assessed factors associated with mortality and potential targets for intervention in a large national sample of children with nontraumatic intracerebral hemorrhage. Using Healthcare Cost and Utilization Project Kids’ Inpatient Database ICD-9-CM code 431 identified children aged 1 to 18 years with nontraumatic intracerebral hemorrhage in 2003, 2006 and 2009. Intracerebral hemorrhage was the primary diagnosis for 1172 children (ages 1-18 years) over the 3-year sample. Factors associated with mortality based on multivariable logistic regression included Hispanic ethnicity (odds ratio 1.9, 95% confidence interval 1.1-3.3), older age (11-18 vs 1-10 years, odds ratio 2.5, 95% confidence interval 1.3-5.0), coagulopathy (odds ratio 3.0, 95% confidence interval 1.6-6.0), and coma (odds ratio 9.0, 95% confidence interval 3.2-24.6). From 2003 to 2009, there was a non-significant decrease in mortality with a significant increase in length of stay from 9 to 11 days (P < .003). In children with intracerebral hemorrhage, coma and coagulopathy had the strongest association with mortality; coagulopathy is a potentially modifiable risk factor.

Abstract TP202: Vertebrobasilar Insufficiency is an Easy to Ascertain and Important Predictor of Cardiovascular Events in Elderly Population: Analysis of Cardiovascular Health Study

Background: Vertebrobasilar insufficiency is a clinical diagnosis which consists of multiple minor recurrent in the distribution of vertebral or basilar arteries. The value of such clinical symptom...

Indicators for Electroconvulsive Therapy among Patients Hospitalized for Depression

This article compares various characteristics, including demographics, comorbid conditions, hospital status, and outcomes, in patients with major depression who received electroconvulsive therapy (ECT) versus those who did not. It seeks to determine if dyslipidemia is an indicator for ECT among patients hospitalized for depression. Data from all patients admitted to US hospitals between 2009 and 2010 with a primary discharge diagnosis of depression were included. We compared patients with depression who received ECT with those who did not. A logistic regression analysis was used to identify the association between patient and hospital characteristics and odds of receiving ECT. All variables that were significant in the univariate analysis were added as predictor vari ables to the stepwise logistic regression model. A total of 925,060 patients with depression were included. Of these, 20,251 (2.2%) underwent ECT. In the stepwise logistic regression, female gender (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.5), white ethnicity (OR 1.8, 95% CI 1.2-2.5), and dyslipidemia (OR 1.3, 95% CI 1.0-1.6) were associated with receiving ECT among the patients with major depression. Large-sized hospitals (OR 1.9, 95% CI 1.2-2.9) and teaching hospitals (OR 3.2, 95% CI 2.1-4.8) were more likely to