Cindy Tiseo

Early Recurrence and Cerebral Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Effect of Anticoagulation and Its Timing: The RAF Study

Background and Purpose— The best time for administering anticoagulation therapy in acute cardioembolic stroke remains unclear. This prospective cohort study of patients with acute stroke and atrial fibrillation, evaluated (1) the risk of recurrent ischemic event and severe bleeding; (2) the risk factors for recurrence and bleeding; and (3) the risks of recurrence and bleeding associated with anticoagulant therapy and its starting time after the acute stroke. Methods— The primary outcome of this multicenter study was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding within 90 days from acute stroke. Results— Of the 1029 patients enrolled, 123 had 128 events (12.6%): 77 (7.6%) ischemic stroke or transient ischemic attack or systemic embolism, 37 (3.6%) symptomatic cerebral bleeding, and 14 (1.4%) major extracranial bleeding. At 90 days, 50% of the patients were either deceased or disabled (modified Rankin score ≥3), and 10.9% were deceased. High CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesion and type of anticoagulant were predictive factors for primary study outcome. At adjusted Cox regression analysis, initiating anticoagulants 4 to 14 days from stroke onset was associated with a significant reduction in primary study outcome, compared with initiating treatment before 4 or after 14 days: hazard ratio 0.53 (95% confidence interval 0.30–0.93). About 7% of the patients treated with oral anticoagulants alone had an outcome event compared with 16.8% and 12.3% of the patients treated with low molecular weight heparins alone or followed by oral anticoagulants, respectively (P=0.003). Conclusions— Acute stroke in atrial fibrillation patients is associated with high rates of ischemic recurrence and major bleeding at 90 days. This study has observed that high CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesions, and type of anticoagulant administered each independently led to a greater risk of recurrence and bleedings. Also, data showed that the best time for initiating anticoagulation treatment for secondary stroke prevention is 4 to 14 days from stroke onset. Moreover, patients treated with oral anticoagulants alone had better outcomes compared with patients treated with low molecular weight heparins alone or before oral anticoagulants.

Migraine and risk of ischaemic heart disease: a systematic review and meta-analysis of observational studies

Several studies have assessed the risk of ischaemic heart diseases in migraineurs, drawing different conclusions. To define and update the issue, a systematic review and meta‐analysis of the available observational studies was performed.

Migraine and body mass index categories: a systematic review and meta-analysis of observational studies

BackgroundSeveral studies have assessed the associations between migraine and underweight, pre-obesity or obesity, with conflicting results. To assess the consistency of the data on the topic, we performed a systematic review and meta-analysis of the available observational studies.MethodsMultiple electronic databases were systematically searched up to October 2014 for studies assessing the association between migraine and body mass index categories (underweight, pre-obesity, or obesity).ResultsOut of 2,022 records, we included 15 studies. When considering the 11 studies following the World Health Organization BMI cutoffs, we found an increased risk of having migraine in underweight subjects (pooled adjusted effect estimate [PAEE] 1.21; 95% CI, 1.07-1.37; P = 0.002) and in obese women (PAEE 1.44; 95% CI, 1.05-1.97; P = 0.023) as compared with normal weight subjects; additionally, pre-obese subjects had an increased risk of having chronic migraine (PAEE 1.39; 95% CI, 1.13-1.71; P = 0.002). When considering all the 15 studies, we additionally found an increased risk of having migraine in obese as compared with normal weight subjects (PAEE 1.14; 95% CI, 1.02-1.27; P = 0.017); additionally, obese subjects had an increased risk of having chronic migraine (PAEE 1.75; 95% CI, 1.33-2.29; P < 0.001). The pooled analysis did not indicate an increased risk of having migraine in pre-obese subjects.ConclusionsThe meta-analysis of the available observational studies suggested an association between migraine and obesity likely mediated by gender and migraine frequency. Further studies taking into account gender, migraine type, frequency, activity, and duration could provide more robust evidence.

Migraine in menopausal women: a systematic review.

Evidence suggests that migraine activity is influenced by hormonal factors, and particularly by estrogen levels, but relatively few studies have investigated the prevalence and characteristics of migraine according to the menopausal status. Overall, population-based studies have shown an improvement of migraine after menopause, with a possible increase in perimenopause. On the contrary, the studies performed on patients referring to headache centers have shown no improvement or even worsening of migraine. Menopause etiology may play a role in migraine evolution during the menopausal period, with migraine improvement more likely occurring after spontaneous rather than after surgical menopause. Postmenopausal hormone replacement therapy has been found to be associated with migraine worsening in observational population-based studies. The effects of several therapeutic regimens on migraine has also been investigated, leading to nonconclusive results. To date, no specific preventive measures are recommended for menopausal women with migraine. There is a need for further research in order to clarify the relationship between migraine and hormonal changes in women, and to quantify the real burden of migraine after the menopause. Hormonal manipulation for the treatment of refractory postmenopausal migraine is still a matter of debate.

The Epidemiology of Atrial Fibrillation and Stroke

The burden of stroke is increasing due to aging population and unhealthy lifestyle habits. The considerable rise in atrial fibrillation (AF) is due to greater diffusion of risk factors and screening programs. The link between AF and ischemic stroke is strong. The subtype most commonly associated with AF is cardioembolic stroke, which is particularly severe and shows the highest rates of mortality and permanent disability. A trend toward a higher prevalence of cardioembolic stroke in high-income countries is probably due to the greater diffusion of AF and the control of atherosclerotic of risk factors.

Declining incidence of intracerebral hemorrhage over two decades in a population-based study.

The incidence and case‐fatality rate (CFR) of primary intracerebral hemorrhage (PICH) over two decades were assessed in a prospective population‐based study.

Hypertension and Stroke: Epidemiological Aspects and Clinical Evaluation

The strong relationship between stroke and hypertension has been the object of several studies and trials. These studies addressed the epidemiology of stroke and hypertension, in order to estimate their worldwide distribution and time evolution, and investigated the effects of the management of hypertension on stroke outcomes. Evidences coming from these studies are essential to plan proper health services, optimise economic resources, and estimate the effectiveness of therapeutic strategies in primary and secondary prevention. Additional suggestions are needed to tailor the pharmacologic management of hypertension on the individual needs of patients and to select the most appropriate treatment to avoid stroke recurrences on the basis of the first-ever stroke subtype. Moreover, an increasing attention has been given, over the last years, to the relationship between the presence of hypertension and the development of an end-organ brain damage leading to early cognitive dysfunctions. A better understanding of this relationship is the prerequisite to promote successful aging and well-being.

Epidemiology of Transient Ischemic Attacks Using Time- or Tissue-Based Definitions

Background and Purpose— Transient ischemic attack (TIA) epidemiology may have changed in recent years as a consequence of improved identification and treatment of vascular risk factors. Our aim was to provide updated information about TIA epidemiology in Italy. Methods— Cases of first-ever TIA were ascertained from January 1, 2011, until December 31, 2012, in a population-based prospective registry. All residents in the L’Aquila district with an incident TIA were included and followed up to 2 years after the event. Outcome events were recurrent TIA, nonfatal and fatal stroke, nonfatal and fatal myocardial infarction, and all-cause mortality. Results— A total of 210 patients with a TIA according to the traditional time-based definition were included (51.4% women); 151 patients (71.9%) with transient symptoms and negative brain neuroimaging were broadly considered as tissue-based TIA, 29 patients (13.8%) had transient symptoms and evidence of a congruous acute ischemic lesion, and 30 patients (14.3%) had an acute neurovascular syndrome. The crude annual incidence rate for traditional time-based TIA was 35.2 per 100 000 (95% confidence interval, 30.6–40.3) and 28.6 per 100 000 (95% confidence interval, 24.1–33.5) when standardized to the 2011 European population. The incidence peaked in subjects aged ≥85 years, in both sexes. At 2 years, outcome events occurred in 50 patients (23.8%) including 15 patients (7.1%) with nonfatal or fatal strokes. Conclusions— Our population-based study found a low annual TIA incidence rate and a fair TIA prognosis confirming the effectiveness of preventive strategies for cardiovascular diseases. We also proved the nonfitting applicability of the tissue-based definition in our district.

Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non-Vitamin-K Oral Anticoagulants (RAF-NOACs) Study

Background The optimal timing to administer non–vitamin K oral anticoagulants (NOACs) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention. Methods and Results Recurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA 2 DS 2‐VASc score >4 and less reduced renal function. Thirty‐two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOACs within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated >14 days after acute stroke. Conclusions In patients with acute ischemic stroke and atrial fibrillation, treatment with NOACs was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days.

O050. Chronic daily headache and body mass index: a meta-analysis of observational studies

Background Many studies have investigated the association between chronic daily headache (CDH) and normal weight, preobesity, and obesity, with controversial results. A metaanalysis of observational studies was conducted in order to clarify the association between CDH and body mass index (BMI) categories. Methods Studies published up to April 2015 about the association between CDH and BMI were systematically searched from multiple electronic databases. We included in the analysis observational studies in the English language with CDH as outcome variables, and pre-obesity or obesity as compared with normal weight as exposure variables. Only the studies which defined BMI categories according to the World Health Organization criteria for the Western population were included (underweight, <18.5 Kg/m 2 ; normal range, 18.5-24.9 Kg/m 2 ;o verweight,≥25.0 Kg/m 2 ;p re-obesity, 25.0-29.9 Kg/m 2 ; class I obesity 30.0-34.9 Kg/m 2 ;c lass II obesity 35.0-39.9 Kg/m 2 ; class III obesity ≥40.0 Kg/m 2 ). Pooled adjusted effect estimate (PAEE) with 95% confidence interval (CI) was calculated to examine the strength of the association using random-effects models. Results Out of 2,022 records, 4 studies [1-4] met the selection criteria and were included in the meta-analysis. The pooled analysis suggested an increased risk of having CDH in obese subjects (PAEE 1.48; 95% CI, 1.10; 1.98; p = 0.009) as compared to normal weight subjects, while the risk in pre-obese subjects was not different when compared to that of normal weight subjects (PAEE 1.13; 95% CI 0.931.39; p = 0.223) (Figure 1). Data analysis according to BMI categories found that subjects with grade II-III obesity had a higher risk of CDH (PAEE 1.94; 95% CI, 1.50-2.51; p < 0.001) than normal weight subjects, while grade I obesity was not associated with a higher risk of CDH (PAEE 1.05; 95% CI 0.43-2.59; p = 0.909) (Figure 2).