Gary Friday

Heart Disease and Stroke Statistics—2006 Update

1. About These Statistics 2. Cardiovascular Diseases 3. Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris 4. Stroke and Stroke in Children 5. High Blood Pressure (and End-Stage Renal Disease) 6. Congenital Cardiovascular Defects 7. Heart Failure 8. Other Cardiovascular Diseases 9. Risk Factors 10. Metabolic Syndrome 11. Nutrition 12. Quality of Care 13. Medical Procedures 14. Economic Cost of Cardiovascular Diseases 15. At-a-Glance Summary Tables 16. Glossary and Abbreviation Guide 17. Acknowledgment 18. References Appendix I: List of Statistical Fact Sheets. URL: http://www.americanheart.org/presenter.jhtml?identifier=2007 The American Heart Association works with the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS), the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Neurological Disorders and Stroke (NINDS), and other government agencies to derive the annual statistics in this update. This section describes the most important sources we use. For more details and an alphabetical list of abbreviations, see the Glossary and Abbreviation Guide. All statistics are for the most recent year available. Prevalence, mortality and hospitalizations are computed for 2003 unless otherwise noted. Mortality as an underlying or contributing cause of death is for 2002. Economic cost estimates are for 2006. Due to late release of data, some disease mortality are not updated to 2003. Mortality for 2003 are underlying preliminary data, obtained from the NCHS publication National Vital Statistics Report: Deaths: Preliminary Data for 2003 (NVSR, 2005;53:15) and from unpublished tabulations furnished by Robert Anderson of NCHS. US and state death rates and prevalence rates are age-adjusted per 100 000 population (unless otherwise specified) using the 2000 …

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493 2. Recommendations for Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis . . . . . . . . . . . . . . . . .494 3. Recommendations for Diagnostic Testing in Patients With Symptoms or Signs of Extracranial Carotid Artery Disease . . . . . . . . . . . . .495 4. Recommendations for the Treatment of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .495 5. Recommendation for Cessation of Tobacco Smoking. . . . . . . . . . . . . . . . . . . . . . . . . . .495 6. Recommendations for Control of Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . .496 7. Recommendations for Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries. . . . . . . . . . . . …

Stroke in the Lehigh Valley: seasonal variation in incidence rates.

We investigated the seasonal pattern of stroke using the Lehigh Valley Stroke Register. This register includes all patients hospitalized with stroke or transient ischemic attack (TIA) from among the 600,000 Lehigh Valley residents. Meterological data were obtained from the National Oceanic and Atmospheric Administration. The study, which uses 18 months of data, included 1,944 cases. Using single harmonic regression analysis, the seasonal pattern of TIA and infarction, but not hemorrhage, fit a sine-cosine wavefunction with a 12-month period (R2 = 41% and 36%, respectively). For infarction, the strongest seasonal pattern was exhibited for women of all ages and for both sexes in the age groups 65-74 and 75-84, but only the sine component was significant. The peak months for TIA were June-August, while the peak months for infarcts were February-April. Correlations between ambient temperature and each type of stroke were computed. A significant positive correlation for TIA was found (r = 0.57, p = 0.01). After adjusting for a 2-month lag between the low for infarction and the peak for temperature, a significant negative correlation was found (r = -0.64, p = 0.01). No significant correlation was found for hemorrhage. Possible reasons for the opposite relations of TIA and infarct are discussed.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: Executive summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses

Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e422 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e424 2. Recommendations for Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis . . . . . . . . . . . . . . . . .e425 3. Recommendations for Diagnostic Testing in Patients With Symptoms or Signs of Extracranial Carotid Artery Disease . . . . . . . . . . . . .e426 4. Recommendations for the Treatment of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e426 5. Recommendation for Cessation of Tobacco Smoking. . . . . . . . . . . . . . . . . . . . . . . . . . .e426 6. Recommendations for Control of Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . .e427 7. Recommendations for Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries. . . . . . . . . . . . …

Prognosis for survival after an initial stroke.

BACKGROUND AND PURPOSE We studied prognosis for survival after an initial stroke in 662 patients who survived at least 30 days after onset while taking into account age, sex, the number of neurological deficits from the initial stroke, stroke type, and five selected medical conditions: hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus, and history of transient ischemic attacks. METHODS All patients were enrolled between July 1, 1987, and August 1, 1989, and were followed regularly at about 6-month intervals until death or the end of the study (mean of 24 months). RESULTS At 6 months, 90.8% of the 30-day stroke survivors were still alive. At 1, 2, 3, and 4 years, the cumulative survival rates were 86.9%, 78.7%, 73.2%, and 72.0%, respectively. Older age and the number of neurological deficits at onset of initial stroke increased risk of death. Compared with patients of the same age, sex, number of neurological deficits, and comorbidities, increased risk of death is present among those with myocardial infarction, cardiac arrhythmia, and diabetes mellitus. Hazard ratios were 1.7 (P = .006), 1.5 (P = .023), and 1.4 (P = .059), respectively. Hypertension and transient ischemic attacks were not significantly associated with increased mortality. CONCLUSIONS This study clarifies prognosis for survival after an initial stroke by taking into account other confounding variables that could also contribute to risk of death.

Control of Hypertension and Risk of Stroke Recurrence

Background and Purpose— We investigated whether low blood pressure increases the risk of stroke recurrence. Methods— A cohort of 662 patients, obtaining care at the 8 acute care hospitals serving the Lehigh Valley in Pennsylvania, was enrolled within 1 month of an initial stroke and was followed twice annually for up to 4 years. Cox proportional hazard models were developed to examine the relationship between risk of recurrent stroke and blood pressure, controlling for other significant risk factors. Our analyses investigated both lowest follow-up and average follow-up blood pressures as predictors of stroke recurrence. Results— There were 52 recurrent strokes among the 535 patients (mean age, 71 years; 51% men) with follow-up blood pressure. The risk ratio for stroke recurrence for diastolic blood pressure ≥80 mm Hg compared with <80 mm Hg was 2.4 (95% CI, 1.38 to 4.27) and for systolic blood pressure ≥140 mm Hg compared with <140 mm Hg was also 2.4 (95% CI, 1.39 to 4.15). For isolated systolic blood pressure (>140/<90 mm Hg), the risk ratio was 2.2 (95% CI, 1.23 to 3.79) relative to <140/<90 mm Hg. Using the Cox model, we also showed that patients who had at least 1 measured diastolic blood pressure <80 mm Hg during follow-up had a reduced risk of stroke recurrence compared with those with diastolic blood pressures 80 to 90 mm Hg (0.4 versus 1.0; 95% CI, 0.21 to 0.88) even after controlling for the possible confounding factors of hypertension and atrial fibrillation on ECG. Myocardial infarction on ECG, history of transient ischemic attack, and diabetes mellitus were not significant predictors of increased risk of recurrent stroke. Conclusions— Our results imply that “lower is better” for blood pressure control as a goal in reducing stroke recurrence risk.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery

The clomethiazole acute stroke study in ischemic, hemorrhagic, and t-PA treated stroke: Design of a phase III trial in the united states and canada

Clomethiazole is a drug with sedative properties effective in laboratory studies of brain ischemia. A large European multicenter trial of clomethiazole in acute stroke patients showed no benefit overall, but subgroup analysis indicated that patients with large infarctions may have benefited from treatment. To confirm this preliminary finding, we have designed CLASS-IHT, the Clomethiazole for Acute Stroke Study in Ischemic, Hemorrhagic and TPA Treated Patients, to be conducted in North America. Patients who suffer large cerebral infarctions and present within 12 hours of symptom onset are eligible. Patients will be randomized to receive clomethiazole 68 mg/kg over 24 hours or vehicle, using a dosing scheme based on the pharmacokinetics measured in the first trial. Outcome assessments include stroke scales, the Barthel Index, and lesion volume. An additional study of health economic outcomes is planned. The primary endpoint for CLASS-I will be the Barthel Index 90 days after stroke. A total of 1,200 patients will be randomized to CLASS-I, and in safety-only trials, 200 patients with cerebral hemorrhage will be randomized into CLASS-H and another 100 to 200 patients will be randomized into CLASS-T. The details of the protocols for all three studies are presented.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary.

It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices and procedures for the detection, management or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative benefits and risks of these therapies and procedures can improve the effectiveness of care, optimize patient outcomes and favorably affect the cost of care by focusing resources on the most effective strategies. One important use of such data is the production of clinical practice guidelines that, in turn, can provide a foundation for a variety of other applications, such as performance measures, appropriate use criteria, clinical decision support tools and quality improvement tools. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force) is charged with developing, updating and revising practice guidelines for cardiovascular diseases and procedures, and the Task Force directs and oversees this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update or revise recommendations for clinical practice. Experts in the subject under consideration have been selected from both organizations to examine subject specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected health outcomes where data exist. Patient specific modifiers, comorbidities and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered but data on efficacy and clinical …

Acute stroke, hematocrit, and blood pressure.

A population-based study of the relation between hematocrit and stroke subtype was carried out among 2,077 individuals using the Lehigh Valley Stroke Register. This register identifies all stroke patients admitted to the 8 acute care hospitals serving the Lehigh Valley area of eastern Pennsylvania-western New Jersey. The mean hematocrit was higher in patients with lacunes than with thrombotic or embolic strokes (p = 0.02). However, when blood pressure was also considered the increase in hematocrit in patients with lacunar stroke was significant only when systolic hypertension (greater than or equal to 150 mm Hg) was also present (p = 0.029); no significant difference in hematocrit was found between stroke subtypes in normotensive individuals. Therefore, we cannot exclude the possibility that hypertension interacts with hematocrit in accounting for the observed association with lacunar infarcts. There was no trend for increased in-hospital mortality for stroke patients in either the low (less than or equal to 30, 30-36%) or high (greater than or equal to 47%) hematocrit groups.