Clara Hjalmarsson

Neuronal and Glia-Related Biomarkers in Cerebrospinal Fluid of Patients with Acute Ischemic Stroke

Background Cerebral ischemia promotes morphological reactions of the neurons, astrocytes, oligodendrocytes, and microglia in experimental studies. Our aim was to examine the profile of CSF (cerebrospinal fluid) biomarkers and their relation to stroke severity and degree of white matter lesions (WML). Methods A total of 20 patients (mean age 76 years) were included within 5–10 days after acute ischemic stroke (AIS) onset. Stroke severity was assessed using NIHSS (National Institute of Health stroke scale). The age-related white matter changes (ARWMC) scale was used to evaluate the extent of WML on CT-scans. The concentrations of specific CSF biomarkers were analyzed. Results Patients with AIS had significantly higher levels of NFL (neurofilament, light), T-tau, myelin basic protein (MBP), YKL-40, and glial fibrillary acidic protein (GFAP) compared with controls; T-Tau, MBP, GFAP, and YKL-40 correlated with clinical stroke severity, whereas NFL correlated with severity of WML (tested by Mann–Whitney test). Conclusions Several CSF biomarkers increase in AIS, and they correlate to clinical stroke severity. However, only NFL was found to be a marker of degree of WML.

A comprehensive risk stratification at early follow-up determines prognosis in pulmonary arterial hypertension

AimsnGuidelines recommend a goal-oriented treatment approach in pulmonary arterial hypertension (PAH). The aim is to reach a low-risk profile, as determined by a risk assessment instrument. This strategy is incompletely validated. We aimed to investigate the bearing of such risk assessment and the benefit of reaching a low-risk profile.nnnMethods and resultsnFive hundred and thirty PAH patients were included. Follow-up assessments performed after a median of 4 (interquartile range 3-5)u2009months were available for 383 subjects. Patients were classified as Low, Intermediate, or High risk and the benefit of reaching the Low risk group was estimated. Survival differed (Pu2009<u20090.001) between the risk groups at baseline and at follow-up. Survival was similar for patients who remained in or improved to the Low risk group. Survival was similar for patients who remained in or worsened to the Intermediate risk or High risk groups. Irrespective of follow-up risk group, survival was better (Pu2009<u20090.001) for patients with a higher proportion of variables at low risk. Results were unchanged after excluding patients with idiopathic PAH >65u2009years at diagnosis, and when patients with idiopathic or connective tissue disease-associated PAH were analysed separately. Patients in the Low risk group at follow-up exhibited a reduced mortality risk (hazard ratio 0.2, 95% confidence interval 0.1-0.4 in multivariable analysis adjusted for age, sex and PAH subset), as compared to patients in the Intermediate risk or High risk groups.nnnConclusionnThese findings suggest that comprehensive risk assessments and the aim of reaching a low-risk profile are valid in PAH.

The Role of Prestroke Glycemic Control on Severity and Outcome of Acute Ischemic Stroke

Background/Aim. Relatively few studies have investigated the association of prestroke glycemic control and clinical outcome in acute ischemic stroke (IS) patients, regardless of presence of diabetes mellitus (DM). The aim of this study was to investigate the importance of prestroke glycemic control on survival, stroke severity, and functional outcome of patients with acute IS. Methods. We performed a retrospective survival analysis of 501 patients with IS admitted to Sahlgrenska University Hospital from February 15, 2005, through May 31, 2009. The outcomes of interest were acute and long-term survival; the stroke severity (NIHSS) and the functional outcome, mRS, at 12 months. Results. HbA1c was a good predictor of acute (HR 1.45; CI, 1.09 to 1.93, P = 0.011) and long-term mortality (HR 1.29; CI 1.03 to 1.62; P = 0.029). Furthermore, HbA1c >6% was significantly correlated with acute stroke severity (OR 1.29; CI 1.01 to 1.67; P = 0.042) and predicted worse functional outcome at 12 months (OR 2.68; CI 1.14 to 6.03; P = 0.024). Conclusions. Our study suggests that poor glycemic control (baseline HbA1c) prior to IS is an independent risk factor for poor survival and a marker for increased stroke severity and unfavorable long-term functional outcome.

The Effect of Statins on Acute and Long-Term Outcome After Ischemic Stroke in the Elderly

BACKGROUNDnAlthough treatment with statins has produced beneficial effects when used as secondary prevention, its primary protective role is still somewhat controversial. Moreover, few studies have evaluated the effect of statins in older patients with stroke.nnnOBJECTIVEnThe aim was to investigate whether treatment with statins decreases stroke severity and/or improves survival and outcome after stroke in an older population.nnnMETHODSnWe investigated the association between previous statin use and stroke severity (National Institutes of Health Stroke Scale [NIHSS]), as well as the effect of poststroke statin treatment on 12-month functional outcome (modified Rankin Scale [mRS] score) in 799 patients (mean age, 78 years), with acute ischemic stroke. The effect of statin treatment on survival was examined using the Cox proportional hazard model, after adjusting for relevant covariates.nnnRESULTSnStatins did not decrease stroke severity and did not improve 30-day survival. However, both the 12-month survival (hazard ratio = 0.33; 95% CI, 0.20-to 0.54; P < 0.001) and the 12-month functional outcome (odds ratio = 2.09; 95% CI, 1.25-3.52; P = 0.005) were significantly better in the group treated with statins.nnnCONCLUSIONSnSignificantly better survival and functional outcome were noted with poststroke statins at the end of the 12-month follow-up period. Statins seem to provide beneficial effects for the long-term functional outcome and survival in the elderly.

Comparative evaluation of treatment with low-dose aspirin plus dipyridamole versus aspirin only in patients with acute ischaemic stroke

BackgroundPrevious studies have suggested that pre-stroke treatment with low-dose aspirin (A) could reduce the severity of acute ischaemic stroke, but less is known on the effect of pre-stroke treatment with a combination of aspirin and dipyridamole (A + D) and post-stroke effects of these drugs. The aim of the present study was to evaluate the effect of this drug combination on acute and long-term prognosis of ischaemic stroke.MethodsPatients without atrial fibrillation admitted to the stroke unit with acute ischaemic stroke (n = 554) or TIA (n = 108) were studied during acute hospital care and up to 12 months after discharge from hospital.ResultsPrior to acute stroke 62 patients were treated with A + D while 247 patients were treated with A only. No beneficial effects of the combination A + D compared to A only were noted on stroke severity and/or acute in-hospital mortality. However, survival analysis by Cox-proportional hazard model demonstrated lower 12-months all-cause mortality in patients discharged with A + D (n = 275) compared with patients on A only (HR, 0.52; CI, 0.32-0.86; p = 0.011; n = 262) after adjusting for age, baseline NIHSS, previous stroke, previous myocardial infarction and type 2 diabetes. We also noted a tendency towards lower all-cause mortality at 3 months with use of A + D, but this was not statistically significant (p = 0.12).ConclusionsPre-stroke treatment with a combination of low-dose A + D does not reduce the severity of acute stroke, nor does it reduce the acute in-hospital mortality. However, treatment with A + D at discharge from hospital is seemingly associated with lower long-term mortality compared with A only, contrary to the results from previous randomised studies. However, our results must be interpreted with extreme caution considering the non-randomised study design.

IMPACT OF AGE AND COMORBIDITY ON RISK STRATIFICATION IN IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION

Recent reports from worldwide pulmonary hypertension registries show a new demographic picture for patients with idiopathic pulmonary arterial hypertension (IPAH), with an increasing prevalence among the elderly. We aimed to investigate the effects of age and comorbidity on risk stratification and outcome of patients with incident IPAH. The study population (n=264) was categorised into four age groups: 18–45, 46–64, 65–74 and ≥75u2005years. Individual risk profiles were determined according to a risk assessment instrument, based on the European Society of Cardiology and the European Respiratory Society guidelines. The change in risk group from baseline to follow-up (median 5u2005months) and survival were compared across age groups. In the two youngest age groups, a significant number of patients improved (18–45u2005years, Z=u2005−4.613, p<0.001; 46–64u2005years, Z=u2005−2.125, p=0.034), but no significant improvement was found in the older patient groups. 5-year survival was highest in patients aged 18–45u2005years (88%), while the survival rates were 63%, 56% and 36% for patients in the groups 46–64, 65–74 and ≥75u2005years, respectively (p<0.001). Ischaemic heart disease and kidney dysfunction independently predicted survival. These findings highlight the importance of age and specific comorbidities as prognostic markers of outcome in addition to established risk assessment algorithms. Change in risk category at follow-up and specific comorbidity predict survival in IPAH across age groups http://ow.ly/EPQ530j765F

Parvovirus B19 in Endomyocardial Biopsy of Patients With Idiopathic Dilated Cardiomyopathy: Foe or Bystander?

BACKGROUNDnParvovirus B19 (PVB19) has emerged as one of the viruses possibly inducing chronic myocarditis and subsequent idiopathic dilated cardiomyopathy (IDCM). The aim of this work was to investigate the presence and long-term consequences of PVB19-DNA within myocardial biopsies from patients with IDCM and to compare the findings with those from donor hearts (control group).nnnMETHODS AND RESULTSnForty hospitalized IDCM patients (age 47 ± 12 y) with mean left ventricular ejection fraction 27 ± 12% were included. The presence of PVB19-DNA in myocardial biopsies and of IgG and IgM antibodies in patient sera was analyzed. The control group consisted of 20 donor hearts. The follow-up time was 112 ± 57 months. PVB19-DNA was found in myocardial biopsies of both patients (73%) and control samples (55%; Pu202f=u202f.25).Three deaths and 8 heart transplantations occurred in the IDCM group, and 6 deaths in the control group (ie, the recipients of the control hearts). No difference in transplantation-free survival between the PVB19-DNA positive/negative IDCM patients or transplant recipients was found.nnnCONCLUSIONSnPVB19-DNA is a common finding in both patients with IDCM and in healthy donor hearts, not affecting prognosis. These findings support the view that PVB19 is an innocent bystander, frequently found in myocardium with low DNA copies, and not a plausible cause of IDCM.

Acute blood pressure levels and long-term outcome in ischemic stroke

Elevated blood pressure (BP) is common in acute ischemic stroke, but its effect on outcome is not fully understood. We aimed to investigate the association of baseline BP and BP change within the first day after stroke with stroke severity, functional outcome, and mortality.

Is Prolonged QTc Sufficient to Predict Survival in Patients with Intracerebral Hemorrhage

We appreciate the interest in our article and the opportunity to reply to Dr. Koza’s most thoughtful comments. It is very difficult to find the best method for correcting the repolarization time, QT; even more so when atrial fibrillation is present. We extensively addressed this controversial matter in our article where we pointed out that even if there are limitations related to its use, Bazett’s formula is one of the most widely used. We are aware that the Fridericia correction is preferred in some circumstances, for example, in relation to pharmacological studies. It has been shown that if Bazett’s formula leaves a strong positive residual correlation with heart rate, Fridericia’s formula leaves a negative correlation, instead. According to expert opinion,1,2 the QT interval should be adjusted for the heart rate, but the best way to do this has not been determined by prospective studies. Dr. Koza postulates that it is the QT rather than the QTc that is related to the risk for malignant arrhythmias, but we would like to point out that several studies have shown that a prolonged heart-rate corrected QT interval is an independent predictor of cardiac and all-cause mortality in both men and women.3,4 Further, the risk for all-cause and cardiac mortality is hardly influenced by the formula (Bazett, Hodges, and Rautaharju) used for correction.5,6 Indeed, as Dr. Koza mentioned, there are several confounding factors, which can affect the QTc